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u <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> aSlate of California Survey Form - Page 1 1 5 - 10 13 2 2 8 <br /> lwMB 101(New 04!04) <br /> California Integrated Waste Management Board <br /> Part A-S u rvey BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- 1 -2 g Inspection Type (Fill one) <br /> Sks Suffix. O +� D V @ Routine 0 Re-inspection Q Referral Q Observation <br /> Local `� �/1)� If Referral,choose referral type(Fill one) <br /> Identifier s4 \` Q CHP Q CIWMB Q Complaint Q Educations Visit Q Other <br /> Business or Facility Name U -- <br /> / ra v I!Y( Inspected By Inspector <br /> 7T�ys 3 <br /> Physical Address <br /> a I a 00 pwo alae Ove, <br /> Tira 1 <br /> (,� Inspection Date O � � 0 <br /> (-)A- <br /> �� Time In Time Out <br /> Business Rep J Title O AM O AM <br /> ' O PM O PM <br /> Te f i � m!f Z W n Operational Status Tirs Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill alithet apply) ( I all the sppty) <br /> Tire Count(Whole/PTE) 0 <br /> 0 Active I*Passenger •Generator &Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — Q End-Use 0 Container <br /> 0 Planned ®OTR <br /> Business Type (FIR all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber c <br /> T , Sys <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other ►r'ctJf./' � �p0�( <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 07 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements forTire Dealers or Waste Tire Generators <br /> 0 Q 1 Other: § <br /> Comments ` �y/���, <br /> 1 7Y1 P� I h chw —1 W.t_7 <br /> -- 0 C PA it A I r L TL's VieK1.2d <br /> Vr0CI67QnA�01_t e—pr (Imdl W-c-1 LSr swTI fAll8�tc�tGS_ &iy - <br /> Inspection Form Included A � <br /> Qp�7��r <br /> Comments Included.0 -- / <br /> Business Re Sig one umber 1 I or'si nature Phone Number <br /> INSTRUCTIONS ON BACK E V p Z Z 3 62081 <br /> ■ White Copy.CIW NIB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0705904.0302 <br />