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� r Waste Tire Survey & Inspection Report Inspection Report Number . <br /> Slate of 1 7 - 1 0 0 6 3 7 3 <br /> t:IWM",B„New 04104) ..rd Form - Page 1 <br /> California Integrated Waste Management Baard <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile- Jnspection Details <br /> TPID- / 5 O o _ Q ' Inspection Type (Fill one) — — — <br /> Site Suffix: O ®Routine Q Re-inspection Q Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Lail 04VAl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ^ <br /> Physical Address L7 — IJ <br /> Inspection Date D / l O D 6 <br /> Time In Time Out <br /> Business Rep Title /J *AM / 7 0 AM <br /> Operational Status Tiro Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)! (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) b <br /> t / 0 Active Q Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive *Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair le 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer Generator,Hauler and End Use Facility �� � IN <br /> ....,F i�j..�, �..`'��'$r b�_..:- - - �..' a .,,n:<.;1?=x. _.''"..`�±4,-. �`CrS,.._•, ��•> s �F-���'�' y <br /> O O` PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. - <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ” ~~ <br /> O Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 'O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers " <br /> O Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e b y <br /> Other: <br /> Comments <br /> P <br /> 54 <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> _ Rep's Signature Phone Number Inspector's Signature Phone Number <br /> Business <br /> INSTRUCTIONS ON BACK IEIXIAIMIPIL E' 1112131 <br /> 62081 <br /> ■ White Copy:CIW NB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0630504.0038 <br />