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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> en„eaIonia SurveyForm - Page1 1 4 CIWMB 181(New 04104) <br /> GlHomnb <br /> la Igrated Waste 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: —1 3 _ I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local t 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 /> Inspected By Inspector <br /> S a� <br /> Ph�rsl al Ad r ss -�> -( - V a 1 <br /> Inspection Date o <br /> Time In Time Out <br /> Business Rep TRIe Q AM O AM <br /> c�� �� •w`�.��. d t a d 0 PM � O PM <br /> Operational Status-.Tire Type Business Role. Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Ir ®Active QPassen Passenger <br /> Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude IV Hauler Q Indoor <br /> O Q 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 ®Trucking Fleet Q Government Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q C b Rubber `— � <br /> Q Service Station •Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q O 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 O 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 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 O 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 10 1 Other: § y <br /> comments <br /> t� saes. <br /> KB <br /> Inspection Form Included:Q <br /> Comments included: — <br /> B Iness R s Sig ture Phone Number I c or' Phone Number <br /> INSTRUCTIONS ON BACK �� � �� E x A AM P E 1. 2 3 — 62081 — <br /> White Copy CIWMB Yellow Copy:Operator Pink Capy.LEA <br /> 0529204. 1175 <br />