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Waste Tire Survey $ Inspection Report Inspection ReportNumber ■ <br /> Btete of B181'Now Survey Form Page 1 1 1 1 01 3 711 <br /> CIWA181B7(New IWIK( <br /> cagfemis Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' _ Q Inspection Type(Fill one) <br /> Site Suffix: 0 Routine Q Re4nspaction Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � <br /> �� Inspected By ) Inspecto�r.{-�1.(�fQ1 ` <br /> Physical Address 3 ( — L D <br /> ►qja ►Aj•� Yb&fivL4,e- <br /> 'JMay*COLJ <br /> f/ a ^'533 f Inspection Date / <br /> �'✓Lt1 Y ( Time In 1 Time Out W <br /> Business Rep Title (L J t,�j �5 (� / O AM O AM <br /> 11 D 0 PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count hole/PTE) C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J 0 Active ®Passenger 0 Generator j@ Outdoor <br /> GPS Latitude _ O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned I Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 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 /> 070 7PRC§ 951-Waste Tire Hauler Registration and Transport of Tires <br /> 953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registrabon/Decai 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 14 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 Farms 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 /> 010 <br /> nQQ Other. § <br /> Comments _/ksn qL& cilawll o, was ct,ll , <br /> SLS , ert 1! r�,r fi rc s ?.S u�45t2 �1� rc' s Curt �r <br /> 4h1 rd c - erg der ca aHd oreylann od t ba- hnAled 'b a y" cS'�'� <br /> uks`e �e J01. L&_)_44n_ Tire--fir-pr a,ram itera*e' d'z*_ ctackss(d <br /> Inspection Form Included:4ONBACK <br /> a � <br /> Comments Included: — s s _6 <br /> s 's SI ns re Phone Num Inap o in t e Phone Number <br /> INSTRUCTIONS X A M P L 1 .2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0605204.0505 <br />