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Waste Tire Survey & Inspection Report inspection Report Number <br /> g Clate of WMB11(Now Survey Form - Page 1 t 3 - 1. 0 0 6 41 1 <br /> CIWMB 181(New 04!84) <br /> Callforrr,i l ilegrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> _ Business Profile Inspection Details. <br /> TPID- Inspection Y 8 3 l Inspection Type (Fill one) <br /> ffi - <br /> Site Suffix: O 1 -J •Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identlfler. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> a.L-tt-�-k W CIIAMI�11 W <br /> S YO 1��Oh 5;4_CV <br /> Inspection Date <br /> I Time In Time Out <br /> Business Rep Title i 2 Q AM Q APA <br /> � PM <br /> l .' QPM <br /> Operational Tire Storage TypeBusiness R <br /> ole <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger0 Generator Q Outdoor <br /> Latitude 0 Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ®Truck ' <br /> Longitude - QPlanned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair i,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 FacilityEN�ORCENIENi STATUS y, <br /> NO <br /> �1aISQe7ri��, 1 . 1y _ R N <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires otice C1f Viola4lon <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. « a <br /> Compliance Deadline <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 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use.FacilitiesQa` <br /> Q Q 14 CCR§18462_Manifest System Requirements for Tire Dealers or Waste Tire Generators �� <br /> Q Q <br /> Other: <br /> Comments 1 tt <br /> oe 6Y� IQ_ - <br /> W.� - <br /> t co c <br /> inspection Farm Included:Q q6q 76th <br /> 7'a3 �6 <br /> Comments Included:Q <br /> Business Rep's Signature one Number In Phone pNumber< <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK ■ <br /> Mo. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0515804.0161 <br />