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Waste Tire Survey & Inspection Report Inspection Report NumberState 0 ■ <br /> nia <br /> CIWMB Survey Form - Page 1 1 9 - 1 Q 1 3 311 <br /> CM1VMB 181 thew nage <br /> CalHomle Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- p. - Inspection Type (Fill one) <br /> Site Suffix: I Q -7 4 3 $ / 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��r� �aMt� �y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name /L- Inspected By Inspector <br /> Physical Adfress T `?j t ;1eA15 <br /> )24 <br /> Inspection Date 0 / O 7 O <br /> Time In Time Out <br /> Business Rep Title q� / O AM 0 AM <br /> (./ f ' © S O PM O 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 /> t 0 Active 0 Passenger 0 Generator lb Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 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 /> 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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459-1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Fonns and Tire 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 /> ��%r/i K�r�Sgr+f�Of�? lYt�t�r✓`Ci �dte-S� <br /> o <br /> _ r k►— �s b���lA ase.114 10-7 X3.8 -c��� <br /> /� vlo%ins -- <br /> Inspection Form Included:0 /�uu <br /> � Comments Included:0 — <br /> usines_s Rep's Signature Phone Number Ins or's Signafure Phone Number <br /> INSTRUCTIONS ON BACK P L E 1[;!1 g 62081 <br /> ■ While Copy CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br /> 0609004.0330 <br />