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r== Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ■ 'n <br /> Rate Cekrurnis Survey Form - Page 1 1 9 - 1 0 134 7 9 <br /> CIWMB 181(New..g. <br /> 4104) <br /> Cdeomle Integnbd Waeta Menepament Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- ^ Inspection Type (Fill one) <br /> Site Suffix: 3 y y 7 0 1 o f 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local N Referral,choose referral type(Fill one) <br /> Identifier: 91wt _kllgelrl r coa , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Z�11 '�, IV Inspected By Inspector <br /> A,& _ N4rA u 4 t, <br /> Physical Address 3 9 0 / Str,Qep R/I kodq <br /> -- <br /> 95ew 7 Inspection Date 0 r l o g / 06 <br /> Time In Time Out <br /> Business Rep TitleV <br /> /"N, 4'e-4. )ia4,� O 7 AM t1 AM <br /> O PM I I = 3 y O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ � <br /> *Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q 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 0 Auto Repair -0—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 /> QQRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> PQ Q RC <br /> §42953-Contracts with Registered Waste Tire Haulers. <br /> i <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§16459 -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 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 Q Other: § <br /> Comments f4V44kC <br /> OF <br /> �'- -�r� �K•�/���k i�"y a.+<- �_y�!�r...e -�at:r^G�7r ,;p ao1� <br /> - er- or a e C 7lf>za�+ 9 v�v �.rsl Vic_ dQFc- <br /> - - nnn d Zino y S. <br /> Inspection Form Included: <br /> Comments Included:Q Business Reps Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACKE X a iM P L E 1 2 362081 <br /> ■ White Copy CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0617904.0254 <br />