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fli <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r State of California <br /> Cgrated Waste <br /> nage Survey Form - Page 1 1 4 1 0 1 3 fi <br /> California Integrated Waste Management Boats <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- n Inspection Type (Fill one) <br /> Z <br /> Site Suffix: d 7 3 7 ,9 <br /> - 01 <br /> 40 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local J If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical�Address / ✓ <br /> 9sara Inspection Date / 3 l 07 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> n O PM 0 PM <br /> Operational Status�.Tl ) <br /> Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) <br /> Tire Count(WholelPTE) f Q (� <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appy) <br /> New Tire Dealer 9 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 Facility <br /> 720000027 <br /> 2951-Waste Tire Hauler Registration and Transport of Tires <br /> 2953-Contracts with Registered Waste Tire Haulers. <br /> 2956-Registration/Decal in Vehicle <br /> §18459 -Responsible Entities Complying with Manifesting Requirements <br /> §18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> §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 <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 010 1 Other. § <br /> Comments -2r-iwtt' Vk-e A09 <br /> 14--9 A011`t ,lr• ee d ._ i ,,it <br /> (, ,,�'�u,,,t�� �t� OK .� rhe a-7� l•-eeL r l-•� �e?�7'�.-!. 1,0,`ol <br /> !•'/o�-r-�S'anl <br /> Inspection ForrnIncluded:Q <br /> Comments Included:0nature Phone Number InspectoPs Signature Phone Number. <br /> INSTRUCTIONS ON BACK E IIIAA X P L E 1 2 62081 <br /> ■- White Copy CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0705904.0321 <br />