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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State WMB 1811C.Imia Survey Form - Page 1 1 8 - 9 0 0 7 7 9 <br /> CIWMB 781(New nage <br /> Callfomia Integrated Waste Management Board <br /> Part A.Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID Inspection Type (Fill one) <br /> Site Suffix: (Q0 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: Scan jmW-�j CO Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> beeperabir? f Tu���a �ress 3 9I a 1 JP� z <br /> Physical Address <br /> �pol S,Va I;jkr� VV <br /> Sf/rk Al 95-90 <br /> ` Inspection Date / b -7 Q <br /> TimeIn G v Time Out <br /> Business Rep TiO V 1 le 0 -7 0 AM / J/ 0 AM <br /> � 0 PM 0 `1 O 0 ® PM <br /> Operational Status Tire Type : Business Role Storage Type. <br /> Tire Count(Whole/PTE) <br /> 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger lip Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years . .x <br /> Q Q 14 CCR§1846D.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q Other: § <br /> t <br /> Comments <br /> r ok 4/1 lnSpef !1)), ' Ptz 5 dam aoA*V--4�)U 1)kj!YEA (AILS VI 40 i <br /> Fvi e i.Gc: 1-ta,ider- kge a`a <br /> -fires D peri Klee.K re ,f Vito eet "vp,, <br /> {land euf s 01wz*16( d aril ota,' sed . No lc"I`iaws <br /> Inspection Form Included:'Q •r��39-io�^ ^�� <br /> Comments Included:Q BusinineeTss7R0epr'sJSS'iv Lgnat/ur�sJ r. Phone Number Ulnspect.7— ature Phone Number <br /> INSTRUCTIONS ON BACK <br /> i I JEJX A p IZ,, 1� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0600404.0028 <br />