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LH; Waste Tire SL �y & Inspection Repor Inspection Report Number <br /> l>« <br /> ill State of California I 1 - 1141266 <br /> Cgrated Waste <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> ?art A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPISite - _ O Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier: ��� jC° �l/� �Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r ` Inspected B <br /> P Y Inspector <br /> lIqlix, rc{r1�b��c< <br /> ` ao - <br /> Inspection Date �s / v l / C) cq <br /> L c)o �C� 11-001v l <br /> Time In Time Out <br /> Business Rep Title f *AM / ®AM <br /> \ - l 0 PM ( Q PM <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ^� V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> f p� ® Active ® Passenger ®Generator IS Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ® 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 Q Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility 11 5e,Nt+o M� <br /> .-,.+'.,Wx<x.,,m.,aa ,.,,, .,"' E5 .E 5. ,e ... ..• ��'f.,..3`, 4� <br /> PRC 42951 -Waste Tire Hauler Registration and <br /> Transport of Tires <br /> Q Q § 9 P <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 t � <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB -� <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days Q ` <br /> Q ® 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <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 /> Comments <br /> Inspection Form Included: Qj <br /> Comments Included: ® --- - ��-�hi - - ---- ��v_ <br /> `J <br /> B s s Sig re _ _ hone Number Ins a or's ignature Phone Number <br /> �� t r I -- 62081 <br /> INSTRUCTIONS ON BACK I Gorrec ryinc �re�ct ) `' i P I I El 1 i ; 3 <br /> WII a Copy:-CIWMB Yellow Copy:Operator Pink Copy:LEA <br />