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�t Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> cMMS 181(em'e Survey Form - Page 1 16 - 0 1 0 41 <br /> CNVMe 1a1(New 04104) <br /> CNNomle Integrated Waste MmeOement Board <br /> PartA-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection <br /> DW <br /> Business <br /> , 0 3 1 0 - O Inspection Type (Fill one) <br /> Site Suffix: O Routine Q Re-inspection 0 Referral ®Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> T_ <br /> Identifier: SQ O �n C "H`'^ q Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name - - <br /> � Inspected By Inspector <br /> F'-^ � <br /> Physical Address 3 Q �. {V( -Fra i-e <br /> N a 01 N eui-to rr <br /> 5hck-bn 04 95,995,9o5- Inspection Date Q 8 S O <br /> Time In Time Out <br /> Business RepTitle O AM Q AM <br /> W.S. Rh-le <br /> rsOPM 0P <br /> V <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r / (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> Q Active O Passenger O Generator j O Outdoor <br /> O ®Closed O Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> O Q Inactive ! 0 Truck <br /> Longitude - O Planned p OTR l O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> O Service Station 0 Hauler O Agriculture 0 Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration[Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 Other: § J <br /> Comments CJ�t2 j �'�fl • n�/` S l�Q Q� p✓' Wf�i r�.I'ltil <br /> - s _Ow cam.as h� <br /> --fres were sold fo 3ilid "ac, 's Ti'�e ' P E.CAfrter. A <br /> ._-- <br /> Inspection Form Included:Q <br /> Comments Included:0 <br /> Business Rep's Signature Phone Number s o Ignature Phone Number <br /> INSTRUCTIONS ON BACK I jj X1 A jMrP I L123 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br /> 0723504.0170 <br />