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rrt <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> $tate n, rnla 1 8 . 1 0 1 3 6 3 5 <br /> CIWM6181 181(Now 04101( Survey Form - Page 1 <br /> Gliromla Integrated Waete Management Board <br /> PartA-Survey _ BLUE_OR BLACK INK PEN <br /> Business Profile -- InspectionD"Is - - - — - <br /> TPID- / S O InspedlonType (Fill one) <br /> Site Suffix: 0 Routine QReinspection <br /> Q Referral Q Observation <br /> Local S' 7 N Referral;choose referral type(Fill one) <br /> Identifier. �'IZ C/����Lti{1 QCHP CIWMB Q 0 Complaint 0 Educational Visit Q Other <br /> Bus(neJsAs nor Facility Name <br /> Q� /_ ✓ Inspected By Inspector <br /> Physical Address <br /> 3 9 � � u.e t3 sYi it/i�tiA <br /> 3 9.3 y et Ci /A, -- <br /> �,�,��v.r Inspection Date <br /> Time In Time Out <br /> Business Rep Title <br /> Q 0 AM 'n // / �AM <br /> / l I O PM v g 'f 6 O PM <br /> — rational Status Tiro—Type ype � Business Role Storage Type <br /> Tire Count(Whole/PTE) 45-7 (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> r ° 0 Active Q Passenger 40 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) - — — <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader 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 0 Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> `1 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements t..� <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB ;. <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 <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 /> 0 Other. § / L,,' _ / <br /> Comments Yom/%>`' 441,12-4 l / C 7i)s le/ev <br /> T1-e.�p,1. - s7 4 r ��� 4 �;4 ,4� g!14 <br /> Inspection Form Included:Q <br /> Comments Included:Q— =F"�• � + �fsg�Oj <br /> Bu mess Rep'a Signature Phone Number Inspector's Signature Phons Number <br /> INSTRUCTIONS ON BACK - E X A AA P El 11 2131 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 017-.19404.0042 <br />