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u Waste Tire Survey & Inspection Report <br />state of California <br />CIWMB181 <br />astleMaage Survey Form - Page 1 <br />California Integrated Waste Management Board <br />Part A - Survey <br />Business Profile I Inspection. Details <br />site Suffix:/ 3 I S 7 3 9- O- 1 <br />Site S <br />Local <br />Identifier:M��,.'� <br />Business or Facility Name <br />Fed Ex Fib; <br />Physical Address <br />ysza s. t��y 9q <br />Business Rep Title <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />I r 0 <br />63 <br />Inspection Report Number ■ <br />1 4.1 01 3433 <br />BLUE OR BLACK INK PEN <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />Inspection Date D 3 / C) 3 / 0(. <br />Time In <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Time Out <br />O I <br />C Q AM <br />D to PM <br />O AM <br />O PM <br />Operational Status <br />TireType <br />Business Role ; Storage Type <br />(Fill one only) <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />(Fill all that apply) <br />(Fill all that apply) (Fill all that apply; <br />e Active <br />Q Closed <br />Q Inactive <br />Q <br />Q Passenger <br />Q Altered <br />0 Truck <br />®Generator i Q Outdoor <br />/Uf <br />Q Hauler 1 Q Indoor <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 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />i Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />' 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Q <br />Other: § <br />Comments o"16,& '1wt,S do j. /k f /1D(c!',7urzS not <br />riof '5*re any useIt/0 icedl anot <br />!a Fed EX Morehouse in San.#a. Clara . Also SGlioettle�Tre (w►ercul <br />5eryiccs a ia-f--hr-e,if+' eoiUs_ £6T5 iwwtl) u <br />Inspection Form Included: Q <br />Comments Included: Q <br />Business Bp's Signature Phone Number Ins ctor's Wnati <br />■ INSTRUCTIONS ON BACK l E X a M P L E <br />White Copy: CIWMB Yellow Copy. Operator Pink Copy: LEA <br />0609004.0047 <br />L' Th i S Iu e E h'-} _does <br />A, ped ±S rzt a teme <br />If <br />Dtfiaic`ca(I� <br />q jG T7 ntn c <br />62081 <br />® ■ <br />