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z:a <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Stat eofCalifornia Survey Form - Page 1 19 - 0 1 3 4 9 9 <br /> CIW (New 04104) <br /> Cellfomla IntegraMBted 181 Waete Management Board <br /> Part A-Survey . BLUE OR BLACK INK PEN <br /> Business Profile jinspection Details -- <br /> + TPID- D - 0 ' Inspection Type (Fill one) <br /> Suffix:Site S 0 Routine Q Re-Inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Ste. JQGL - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name CJ Inspected By Inspector <br /> 'Oda to Tre- <br /> Physical Addiess <br /> 13D5- S, <br /> S- �pwtvv.ov c S� <br /> Inspection Date <br /> n � SZr6 <br /> Time In Time Out <br /> Business Rep Title O AM OAM <br /> ��h <br /> I O \ , f l] O �� O PM O PM <br /> �( W Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a !� ` f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active (S Passenger ®Generator if Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I&Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR ®End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station (f 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 1 <br /> :x <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 Fortes and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 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 q <br /> 1010 Other: § <br /> Comments <br /> `s a.P .mares est a,Kd w vv► ,^ <br /> s hatLuw b �s fqc ' reFte ; " s ono(c Wva-i �f <br /> I i.lSPF,�.*kcs' _ '�6rr co le.�� ` Cu5 s 2 �u'e USC r A (4 . <br /> Inspection Form Included:Q R <br /> Comments Included: �Aa QW4(n <br /> Au. s.es.Rep's S eat re Phone Number Ins ctor s nature _ P one Number <br /> INSTRUCTIONS ON BACK rf �t p ( 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br /> 0708104.0071 <br />