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Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr C Mele of California Survey Form - Page 1 ( 8 - 1006531 <br /> - <br /> CIWMB 7811(New g <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection O ' Inspection Type (Fill one) <br /> Site suffix: 7 ( 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> N� ,� Camp 3 Y _ t <br /> Physical Address <br /> , 1 C'i,\ 0.8 <br /> Inspection Date O q, / ) 0 / 0 _5 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> crw�G 0 l 3 v 0 PM O PM <br /> S <br /> Operational Status Tire Type - Business Role -Storage Type <br /> Tire Count(Whole/PTE) v (Fill one only) (Fill all that apply) (Fili.all that apply) .(Fill all that apply) <br /> ®Active Q Passenger 4 Generator .Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q.COntalner. <br /> Business Type (Fill-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 /> .0 <br /> uel.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 S Other \3"It das <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility i <br /> r <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire HaWers. <br /> O O PRC§42956-Registration/Decal In Vehicle c ." <br /> O O <br /> 14 CCR§78459--Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB m <t } <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days ' s <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest.System Requirements for Registered Waste Tire Haulers ' rw ` <br /> Q, O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q O Other. § <br /> Comments Y <br /> / <br /> e SIJ CCC-t�Ytg/// reoQ OVA SLi• - <br /> e It trot.�.:a„A m r , �. C.�/Q�r•.. Entered <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signatffre Phone Numb Ins'. Phone Number <br /> _ _, 62081 <br /> INSTRUCTIONS ON BACK > a E P L $ ,2 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0529204. 1177 <br />