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te a l,o 6r3 <br />rnLee�alrn l�S�(�, <br />¢iii Sflafl9 or Ls6lParrtlO � � � Vahl � 6c(WMs 901 (Hew 04104) �' u r� 'rta li i lP l9 4 . 8_0 .. . <br />CallfCrllld lana®ratc�LN&StO Mnnug911i3F:S Boars} G- -Bp BLUE <br />(DR E,LACK HIA PEM <br />Business Profile <br />_ <br />Inacation Type (011 one) <br />TPID - p <br />5i Suffix: ® Routine® Re -inspection Q Referral Q Observation <br />—.. <br />Local-^� If R4ferral, ctio ge referral type (Fill uric) <br />identifier: r O CHP Q Cl1!HMB 0 Complaint Q Educatlonai Visit Q Other <br />Business or Facility loaner' In5pected By Inspacw <br />`4 �w�• `J �,�Y �i�,�A, � 4�1d u�'�6'''rP`� �� � 0 � . -... I � )'6i4t{a.. <br />._... <br />( , 1 <br />t�luyeioel Adan 5s -...-_._._...... _.... <br />p�...... a y._.._._W _._... <br />Business Reps Tiele <br />Tire Count (WholeIPTE) <br />GpS Laidzude <br />O <br />Longitude – <br />Business Typa$ (Fill all that apply) _ <br />0 New Tire Dealor Auto Repair Q Trucking Fleet <br />O Used Tire O(ealor Q Auto Body Q Car Dealer <br />Inspection Date <br />Time In <br />®AM <br />® PM <br />operational Status _...._ <br />(Fill one only) <br />41 Active <br />0 Closed <br />Q Inactive <br />Q Planned <br />Tire Type <br />(t=ill all that apply) <br />0 Passengor <br />O Altered <br />0 Truck <br />Q OTR <br />Time out <br />f� <br />Q AM <br />® PM <br />Business Role <br />Storage Iypse <br />(Fill all that apply) <br />,(Fill all that apply) <br />® Generator <br />O OVtdaor <br />Q Hauler <br />0 Indoor <br />0 End -Use <br />® Container <br />_ ..... ....... ......... . _-...... .... <br />Q Government Q Ratreader Q Dismantler <br />O Collection 0 Crumb Rubber <br />d service Station Q Hauler 0 Agriculture Q Shredder Olher <br />Part B - Inspection of Waste Tire Dealer, Generator, hauler and End -Use Facility <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tiros <br />Q <br />Q <br />PRC § 42953 - Contracts with Regibtarad Waste Tire Haulers. <br />® <br />O <br />PRC § 42956 - Registration/Decal In Vehicle <br />b <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />Q <br />14 CCR § 18459.1 (a) (h) (c) - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459,2.1 - Submittal of Manifest Forms and Tire Trip Log& within 90 days <br />Q <br />O <br />114 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460,2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />QI <br />Q <br />14 CCR § 18462. Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />® <br />O <br />Other: § <br />Q Tire Derived Fuel <br />nkerma lr a%lea- Repa4 <br />C®rramearts �FesStb.tos� ._w�._.._..-_.._._`�Gi� <br />.✓ <br />o lj <br />0-0. ... Us a4._._gn4l[ - I iasq-e _- i u' e �..._, ... <br />° <br />and <br />_.,F.-nspeas._ <br />Inspoetion Form Included: t0 <br />C®cxartataretb Inv:uderV <br />Baasinebs Ro3a's SInnlq' Rhonq. umber.__.__ In ctor°s 3 nature phone Number_ <br />--....-.. ...---- �'��•,}� 'T i�ry r —. - - --- - 62031 <br />iNSTRU1t7.TlI0,N5 ON BACK 111.213 <br />White Copy: CIWM3 1'G tots Copy: Opivralot Pink Copy: LES <br />TO 39Vd Hl IV3H !V1N3WN0dI/;N3 8CIOP91) 6Z=91 sggz/6G/'11 <br />