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ill <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> 1 State of Ca llfornia <br /> cgrated asteMaage Survey Form - Page 1 1 5 . 1 0 0 6 5 9 4 <br /> California Integrated Waste Management Board <br /> Part A-Survetf BLUE OR BLACK INK PEN <br /> �Business Profile Inspection.Detalls <br /> TPID- t6 Inspection Type (Fill one) <br /> Site Suffix: t 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: d,r�_ l_7/U_cir..c.,2r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 9 ( 0 / <br /> Inspection Date IY <br /> Time In Time Out <br /> Business Rep//���� Title ? (� *AM / +♦AM <br /> 7'4 (i�LQ+��L / D 3 7 O PM L S Q PM <br /> �a_s <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 41 Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor 110 <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> LQ 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 l <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End Use Facility It'oRCfiEMENt$TAT <br /> V I q HAUCI Notice Of Violation <br /> Q Extenssan� <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires r <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. t <br /> pmR&�t1ce Q4adiinv, <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O 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 /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years � � <br /> Q Ov.. <br /> 14 CCR§18460.2-Manifest-System Requirements for Registered Waste Tire Haulers .,•z�,.z <br /> Q Q 14 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 /> Q Q Other.. <br /> t § <br /> Comments reel A-_I dr` �C �.,..I 6•�.� �'y`C ��� <br /> 4,40 1zr� ctiyr� .1,�.�✓, ��- "sT C�c�ort 9�LC,�, us�4'� <br /> Inspection Form Included: <br /> Comments Included: - <br /> "e, 4 gna ure Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BA& �� I �,) .:,,�: L� ;':h'i��tt� .:�I�r� �� ���� p����� ��� ��� �P�L� �� �1 ���� 62081 <br /> White Copy:CI MS Yellow Copy:Operator Pink Copy:LFA <br /> 0628404.0065 <br />