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21, <br /> Waste Tire Sfty & Inspection Repor% Inspection Report Number <br /> State of California <br /> CIWMb Waste <br /> eManage) Survey Form - Page 1 1 7 - 100803 1 <br /> California Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile_ Inspection Details <br /> TPID- © / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMH 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressyC, <br /> Inspection Date O f / C_ <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> . -I O PM O PM <br /> �I(tiNAl�L� <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) © U © 10 [ (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> 0 Active &Passenger 0 Generator 0 Outdoor <br /> Dt0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude0- 0 End-Use 0 Container Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> *New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityNFQ ,�' ;�ir ` N' <br /> .'A HAULING AND <br /> -MANFEST Rimul MBNTB <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> clot>l <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> § <br /> 0 0 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements <br /> 0 4 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMH f `r <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years rim„ �Li%/� �`,�j iif/rte,,/✓' <br /> SO.ter��,;,.r <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> �� <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities %i" y ;y�✓�s ,/,�/// <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators "'y%... <br /> 0 0 Other. § <br /> Comments n/fgn 1,4 _ 4-y f>Y,,5 t 4e, i 5;22c +e`er <br /> I►�t -{fit l�. f%-1an 14eq - /%') _/5l ­26(9 y' d4,14! ' 5(-'.3-d L- <br /> v�1 <br /> rlckl_lp, ja <br /> Inspection Form Included: 0 <br /> Comments Included: �`� /-73 _ — �� <br /> as Rep' gnature phone Number I actor's Signa ure Phone Number <br /> INSTRUCTIONS ON BACK �� )( AI p t 62081 <br /> lI <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LEA <br />