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=t , Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> CIWMS`1(N- Survey Form - Page 1 1 1 - 1 01 3 4 3 9 <br /> CIWMB 181(New nag <br /> CHifomle InUBMed Waeb Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ^ _ Inspection Type (Fill one) <br /> Site Suffix: y <br /> 01 Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> H Referral,choose referral type(Fill one) <br /> Identifier: �p� C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busfness or Facility Name <br /> Inspected By Inspector <br /> Ry)-e_ Li h u✓�i t-e r� <br /> Physical Address 3 – C Jena, Y, <br /> Lf?-y - - E M�,rlPCs cti Z <br /> ,sCJI„g: �1L �yl6,I s Inspection Date O / O <br /> 1 LX K ' Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Fill {' �kf�Ct►1 IGL�L�✓� O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r p Active Q Passenger Q Generator Q Outdoor <br /> -- OJ Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O ®Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 <br /> Q Q 1 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 114 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments R,,,�i14� 11tS�1QC � t . lC�. iTi��61�i1✓lGi 1�l�aS �0�r?[� .�D <br /> -fy warkk,- 6n sibe . Mo -Etre roar n.-tepkaiire-iS p..er-FrarMed ovI siff <br /> -hv�S o h St+e. rnacAiyat-t?d 1n cidi fv . Phone call jTcWe_ Scar- <br /> 0 w 11 `i- Y E'b_b_ f i Y-16S _Ckr-e_C n S i �Q <br /> Inspection Forth Included:Q P <br /> Comments Included:Q <br /> Business Rep's 51�{nature Phone Number d�19ntur. Phone Number <br /> INSTRUCTIONS ON BACK E X A M PIL 1 2 62081 <br /> ■ While Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0615104.0578 <br />