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Waste Tire VOY & Inspection Repft#lnspection Report Number <br /> 11AA State B California Il - 1127493 <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A_Survey- _ BLUE OR BLACK INK PEN <br /> ,Business Profile rinspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: <br /> I <br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier �C ,+ /y C� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - ✓ -- - - <br /> Business or Facility Name Inspected B <br /> Sa�vc�. P Y Inspector <br /> Physical Address 65o <br /> 1 ✓� Inspection Date j `� /'7C'ij <br /> 1�Y1ue� a5 l L ut <br /> Time In Time Out <br /> Business Rep Title �] 11--�- Q AMQ AM <br /> PM 0 PM <br /> - - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®P Active ® Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-UseQ Container <br /> -- - __L <br /> Business Type (Fill all that apply) <br /> IN New Tire Dealer 0 Auto Repair 0 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 Facility <br /> x x HAUI.I.NG1N'R MANIFEST E)VIENTS'' � <br /> �d <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle M ,a <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements . <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB `n,, <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 /> 0 0 Other: <br /> Comments — <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - -'y <br /> in�p s nature Phone Number y Ins ct Signature Phone Number <br /> 9 <br /> INSTRUCTIONS ON BACK Go � �` s 62081,; £hti C <br /> ._. .a. <br /> White Copy: I B Yellow Copy:Operator Pink Copy:LEA <br />