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_= Waste Tire Survey & Inspection Report Inspection Report Number <br /> SCalifornia Survey Form - Page 1 11 - 1 01 0 7 2 5 <br /> CTWMB IWMB 197(New 04104) <br /> California Integrated Waste Nanagement Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- ( , - Inspection Type (Fill one) <br /> Site Suffix: j 3 g 5 `f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local (7 1 If Referral,choose referral type(Fill one) <br /> Identifier: �LTtwrr�� ` V Q CHP Q CIWMB Q Complaint Q Educationai Visit Q Other <br /> Business or Facility Name U — <br /> g� ye sale's inspected By Inspect/o�r.,f r <br /> Physical Address I `\J��<'�U 3 / <br /> 1 IL <br /> C�J (//� Inspection Date O / h <br /> % � Time In Time Out V <br /> Business Rep Title O AM Q AM <br /> Crb �iIP !� PM — QPM <br /> ro Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> )� Q Active Q Passenger Q Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I Q End-Use Q Container <br /> Q Planned Q OTR <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 /> 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 taUeroJes <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility J <br /> § 9 <br /> Q ' Q PRC 42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIW MB <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 /> 00 <br /> 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 /F n r, J S to e & <br /> `0 M r Gln) �iC�-�r", , Mb uwr r �� 1 7�fM �1 d a <br /> 1 <br /> jjvfi L2G ✓�_!n 4t`Y2 a Cf►'fit W . <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Ignature Phone Number �e ors Si at ire Phone Number <br /> INSTRUCTIONS ON BACK A M P L E 1 '2 3 62081 <br /> ■ 0716504.0053 White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />