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=«- Waste Tire Survey & Inspection Report Inspection Report Number <br /> fCarnia Survey Form - Page 1 1 8 - 0065 89 <br /> C`NM181(New ew 04!04) <br /> California Integrated Waste Management Board <br /> Part A-Survey__ - _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 QC / / Inspection Type (Fill one) <br /> Site Suffix: ' ?j (� (� 3 r 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: q �� _ ���r CND Q CHP - Q CIWMB 0 Complaint 0 Educational Visit .0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddresress <br /> 1 ^ Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> QPM QPM <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 /> f <br /> 0 Active Q Passenger 0 Generator Q Outdoor <br /> O •Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - End-Use 0 Container <br /> Q Planned Q OTR Q <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> M-Waste Tire Hauler Registration and Transport of Tires <br /> -Contracts with Registered Waste Tire Haulers. <br /> -Registration/Decal in Vehicle <br /> 59 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§ 459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 6 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators - <br /> 0 0 Other: § J� <br /> Comments g�„ / - _ t�1��5 Gi�f�C !5 _ <br /> Inspection Form Included:.Q <br /> Comments Included:0 <br /> 13usiness'Rep's Signature Phone Number or's Signaturi-7.7 Signature-7.7Phone Number, - <br /> INSTRUCTIONS ON BACK ALIE <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 T F8104.0172 <br />