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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> state of MB18r(New Survey Form - Page 1 i 9 - 1 0 0 6 6 9 1 <br /> CIWMB 181(New 04/04) <br /> callfomle Integrated Waste Management Board <br /> Part A-Surve _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 7 -7 5 - Q Routine is Re-inspection Q Referral Q Observation <br /> Local �,-, If Referral,choose referral type(Fill one) <br /> Identifier: J Da�hi� co,,,_{7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �/�.'^�ljOr a. `✓"ter.-V'�o(-ems T <br /> Physical Address <br /> 1-2-A 0 ct._-(C11_ <br /> LollL� --- - -- -- - - <br /> °►Sia Inspection Date [� S <br /> GlQ <br /> Time In Time Out <br /> Business Rep 1 Title O AM O AM <br /> O PM —O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D 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 Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> iQ 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 /> INK <br /> r <br /> QQ PRC§42951-Waste Tire Hauler Registration and Transport of Tires PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q <br /> - �•;, <br /> Q Q PRC§42956-Registration/Decal in Vehicle z �' <br /> �r <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements t <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 O <br /> 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 1 Q (Other: § <br /> Comments <br /> L <br /> I��►��— ,�� ►_g,.r 9 s 16 <br /> L ,- <br /> -�„�.-1� L►,P �_p r/2-/���--mss. <br /> eh S ( S �Z� <br /> Are., � arc- .-- .- <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signaturee - Phone Number ectoearsidnature Phone Number <br /> INSTRUCTIONS ON BACK X( A P 1112 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br /> 06F 0604.0216 <br />