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Waste Tire Sulky & Inspection Rep ` rL X11 In�p eta epoi�t Number <br /> State of California l <br /> Cgrated arteManagei Survey Form - Page 1 0 0 0 4 2 <br /> California Integrated Waste Management Board . . <br /> Part A- Survey - -- -- - BLUE.00 BLACK INK PEN <br /> fBusiness_Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address 9 <br /> 3 33 w lwr C, <br /> Inspection Date V / �j J u 2t <br /> Time In Time Out <br /> Business Rep Title O AM O AM ! <br /> 0P 0P <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f ' '` > !(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply). <br /> 'T I #Active ® Passenger 0 Generator o <br /> O O Closed O Altered <br /> GPS Latitude - O Hauler ,I® Indoor <br /> O Q Inactive #Truck <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder ® Other U^IR <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENRC3uFtF IRM",I � <br /> I:V HAOLINOANp MAN FEST REQUIREMENTS + NQtI `s�fxy#r�tAttl n 3s itlietl �j <br /> E�IPNCY4N&4 re Ha stration rt of Tires i <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Gampllat�� <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements L}ptp D <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIW MB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ,''I'j�y/�, ✓�may, %�� 3 <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Lags for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q ® 14 CCR§18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: <br /> Comments <br /> 15 C-GLY, nom `tw-�5 L: ��ti� -L �� �-� <br /> Inspection Form Included: <br /> Comments <br /> Business Rep's Signature Phone Number I ector'e Signa ure Phone Number <br /> _ "' 62081 <br /> INSTRUCTIONS ON BACK [Cora�t: In+�nef: ' E NY P L E 2 2 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />