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LFCS Waste Tire Surve &.Ins Inspection Report Inspection Report Number ■ <br /> Y p P <br /> atetev181(Now Survey Form - Page 1 1 8 . 1 01 3 6 61 <br /> CBNMB 181(New 04704) <br /> Cell(omle Ntegreted Weete Management Board <br /> Part A-St;= BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ O / Inspection Type (Fill one) <br /> Suffix:Site S / 0 Routine Q Re-Inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: sir_ OQ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> -_ <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address — <br /> 3 q / d ( ct8,9tP;7Y:Adit <br /> Ale <br /> —7 Inspection Date 0 -7 <br /> Time In Time Out <br /> Business Rep Title 0 AM / ` *AM <br /> O PM ( D D 0 PM <br /> Operational Status The Type Business Role�(Flll <br /> e Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that applthat apply) <br /> Active 0 Passenger 0 Generatortdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor i <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Buslness Type (Fill all that apply) <br /> i New Tire Dealer 0 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 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 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 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 1 Other: § <br /> Comments � M „q�7 <br /> mob"" t �1. �l -r Iii r car <br /> ��-6� u� /a� Q '� 7'jo �ecse.or��- �y ter ' <br /> � - Qt<�yed �s �,�/�.+�c ri�.y,�a �. �,•ire � <br /> AO V/blame�1 <br /> Inspection Form Included:01 <br /> l-/%,7Mal <br /> Comments Included:Q r— ZYC!��� <br /> /- �(/ �' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK jEjXjAjAkjPjL1E1 1112131 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0622104.0008 <br />