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ELE: <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> - Cgrated Waste Management <br /> Survey Form - Page 1 1 7 - 1 0 0 6 7 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` 7 _ inspection Type (Fill one) <br /> site Suffix: , 1 <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local .r If Referral,choose referral type(Fill one) <br /> Identifier: a,,, ,o of C�„u - CI�w 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U - <br /> r Inspected By Inspector <br /> Physical Atldress <br /> 56 L�t6v' �_A Z c>L Inspection Date t7 Z Z C> S <br /> Time In Time Out <br /> Business Rep Title Q AM <br /> r Q AM <br /> ® PM o Z ® PM <br /> LE 6-,, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) _ _ r\ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GpS Latitude . <br /> 0 Hauler ®Indoor � <br /> o 0 Inactive ®Truck ad <br /> Longitude - 0 Planned 0 OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ® Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator, Hauler and End Use Facilityn' M fi <br /> f ,- w''"��" i P, y'..�-�r,�r� .�.^�.�.•,;. -<r N..g., �-,.. ..:p .x<,� � ;.. d 4 a m �`r.,�5, <br /> L'? �` �i idYa� Y t��i%iF1,� ,,'„ `' . .. . .. �'a','r ;�•. :Y+ ���.:4.�'�' � �`�r� ` � �.r '.t �a`'�c�a1�iP yi ���;* <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. z _� ' 3tx <br /> 00 § s - � a � <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements : <br /> •rt;?cx <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers QIc <br /> x } <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities € <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 0. Other: § s c x <br /> Comments <br /> ICY' t?S-t�(9V� — O W' �� ,V�.S C'V, <br /> L OGC 1�lwl 1ti �i: A�,A <br /> ii;ad <br /> MID <br /> Inspection Form Included: <br /> Comments Included: ` } <br /> Business Re ' Signature Phone Number lits ector'S Signature Phone NUmbet <br /> INSTRUCTIONS■ ON BACK a }t� �•. , , P E 62081® ■ <br /> White Copy CIWMB Yellow Copy;Operator Pink Copy:LEA <br /> 0529204. 1083 <br />