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OIVT-04-200" THU 10:49 AM C07AD1TRAII,ERISAI,ESII.I.CRsPAGJDG PAX:2099313000 P. 002
<br /> Waste Tire'S ® 8� Ispe �or�' Repor :Igaion Report Number
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<br /> CIWMB"4.1►te«,e.rA, Surrey` Form Page
<br /> Californiaira
<br /> orn7a Integrated Waste 1nsyemaM Beano
<br /> PartA-Surve BLUE OR BLACK INK PEN
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<br /> TPID- J C ? Inspection Typo (Fill one)
<br /> Sitesi '.i��, '. ® RotiUne `:Q Re-Inspection O Referral. Q Ouftcbaerylt[on
<br /> Local N Rs(erral,choose iefen-al.tyles(Fill one),
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<br /> New Tire Dealer Q Auto Repair Trucking.Fleet' .Govemmein .Reveader0 DlsmanGor' p Tv@ Oeriv�d Fuel
<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer..'.: Q Collection. Q Crumb.:Rubber`.
<br /> QSeMce Station F lauler . . 0-)@
<br /> . Q Q.plgricuRure Q Shredder• �Other
<br /> Part B•-•Inspection-of Waste Tire:Dealer,'Generator,.Haulerand.End-Use facility !VNF.O:RCENIENTSTAIUS
<br /> V'-7 .A HAUL{NG,ANDi NIAHl1FEST•REQUIREMEN'E8` w .
<br /> iYotice 17f Yolabon ..Q EXt�rris}on {
<br /> Q Q PRC§4295t-•Waste The Hauler Registration and Transport of Tires
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<br /> §.42953, oracts with Registered re auers- 1 i
<br /> Q Q.. PRC, Cntitd WTiHl <Compiit�nt-e IDeadllne I
<br /> Q 0 PRC§42956-.Registration/Decal in Vehicie
<br /> Q•'.Q 1a CCR§'t8a58. Responsible Entities Complying with'Manifesting Requirements,
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<br /> Q .Q :14 CCR.§18459.1 Tire Program ID Number from CIWMB
<br /> § p p ogs wlthlrt.90.da s R fior Not/of
<br /> 14:CCR 18459;2.1-Submittal of Com rehensi a Tri I_ ( �-
<br /> Q 14 CCR§18459.3-Retention ofCornprehenslye,Trip Logs fora year
<br /> a i 0 14:CCR§'18460,2-Manifest System.Requirements fQrRegistered.Waste Tire Haulers• 'Q Refensd 1 C11MMB Enforcement'_"
<br /> 14 CCR§18451 Manifest System Requirements for Waste Tire End-Use FaCiritie6 _
<br /> v _0 14 CCR§18462 Msmfest'System Require nts.for Tire Dealshr..or Waste Tirire'Generstors Cor}tpllattu No Vigtatlons
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