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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> C4S4Callfornla Survey Form - Page 1 12 - 1013695 <br /> MB <br /> 181(Naw 04/04) <br /> California Integrated Waate Management Board <br /> PartA-SurveyBLUE OR BLACK INK PEN <br /> Business Profile - Inspection Details <br /> TPID- / Q - Inspection Type (Fill one) <br /> Site Suffix: I.Routine Q Re-inspection Q Referral Q Observation <br /> Local (7 /Q If Referral,choose referral type(Fill one) <br /> Identifier. �iyt p� �lcUk 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Jam,k� 20 4e 3 � ..a <br /> Physical Address 9 - / O L- <br /> u.13l30/N%F•�Vfil <br /> n Inspection Date , p / 3 O <br /> (�J\ Time In Time Out <br /> Business Rep Title r� 0 AM <br /> V / I iC/ 3 -.2 QPM / / Q (� 0 AM <br /> Cls.A.re� v-tit-1�'r�e 3' Ocdlser J 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 /> 40 Active Q Passenger ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 1Q <br /> Q HauleQCInodnotori <br /> nOQ Inactive 0 Truck End-UseQaLongitude Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 /> LO Service Station Q Hauler 10 Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer,Generator Hauler and End-Use Facility R <br /> S�ffi ,.a��� ._.r�,.-.f.', .;, '�' .54. a-;.i..''.3'... 'S�fcr•4 ti c tA"-x7 4 t Rta'.�•w�LR <br /> QY Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires ex A f <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle � �'= T.-..•�"+� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements `' '<• <br /> 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 /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q. <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities 1~"4• ` < <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § <br /> Comments ;,//�--,, i� ,al•>n y��1 Q/„-, „_ d �c{ _ � tl� Js��� <br /> 9 use u�/w�fe �� are c�wa�aC �ra•��/>��..�` vac "04--z /Bei it�iT'e <br /> e-,_Q.l A`'` - C ` <br /> 04- txe bole <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Busin Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON ACK 'Q.-ow= 62081 <br /> _1 112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA ■ <br /> 0633304.0077 <br />