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aWaste Tire Survey & Inspection Report Inspection Report Number <br /> stelaofCaldorna Survey Form - Page 1 16 1 01 3 3 3 6 <br /> I. �e� M oaoa) <br /> callfomia Integrated IN,1,Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine ®Re-inspection Q Referral Q Observation <br /> Local �-- If Referral,choose referral type(Fill one) <br /> Identifier: �� Hll- (;,_4y I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C:0M04 :;A bligqL q <br /> Physical Address �J 3 ( <br /> / Inspection Date <br /> q <br /> -�5- Time In 1 Time Out <br /> Business Rep Title B AM O AM <br /> j 0 0 0 PM O PM <br /> 6 GI Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W holelPTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' Q Active Q Passenger *Generator a Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - ®OTR Q End-Use Q Container <br /> Q Planned <br /> Business Type (FIN all that apply) <br /> Q 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 0 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 /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q I O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other. § <br /> Comments & -.�- , 4".vr • 3 Y�Kn dic/-cK+,h�It--oT6L� <br /> -t/gyp <br /> ?_z <br /> 0 <br /> 9t��s <br /> Inspection Form Included:Q .. <br /> Comments <br /> Bust n&s ReFs nat Phone Number Ins or's Sigriature Phone Number <br /> INSTRUCTIONS ON BACK A lilt P LIE1 1112131LIE62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LFA ® ■ <br /> F_t-105204.052 1 INNER <br />