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y , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of mme'8'(Mrnla Survey Form - Page 1 1 5 - 1 0134 8 3 <br /> CMIMB 781(New 04!04) <br /> CaBfortda Integrated Waste Management Board <br /> PartA-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /J r Inspection Type (Fill one) <br /> Site Suffix: y 7 7 7 D ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �y �y If Referral,choose referral type(Fill one) <br /> Identifier: t/04�Gc�� �.�E� it Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name a Inspected By Inspector <br /> L",Ox <br /> Physical Address 3 0 S'uaat7ry 4 <br /> /day -. <br /> ,S'7/Y, ><a�t 9sez�D Inspection Date d S / D <br /> Time In Time Out <br /> Business Rep Title�J O AM 9 <br /> / © AM <br /> : � <br /> � a PM / ti PM i <br /> - Operational Status' Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / S"D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 4D Active 0 Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler I � Indoor <br /> D Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q 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 i <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q14 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 /> 00 Other: § <br /> Comments '� f y��,.o.��L•� T""`r Q/� �iAC �(,c-f �Qn..,�/,� � J <br /> Z, ., 1,,-e i^ <br /> _/i/'y reu.wy2AAw_/� <br /> Inspection ForthIncluded: A.R..'. <br /> Comments Included:Q <br /> Businignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I I: R A M P I L: 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0617904.0419 <br />