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Waste Tire Survey & Inspection Report Inspection Report Numberstate of . <br /> CrWM <br /> omia Survey Form - Page 1 1 3 - 0 1 0 $ 1 8 <br /> CONMB 181 181((New m <br /> 04!04) <br /> CelMomla Integrated Waste Manageent Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection p 5- Inspection Type (Fill one) <br /> Site Suffix: D 7 D 0 Routine Q Re-inspection 0 Referral Q Observation <br /> Local /t If Referral,choose referral type(Fill one) <br /> Identifier. CLK 04i?7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 7 I 0 r <br /> J!'' Grin 9s�6 Inspection Date 07 <br /> Time In Time Out <br /> Business Rep 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 /> r 0 Active Q Passenger ®Generator Q Outdoor . <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility51 <br /> _.r f <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 t <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other. § ; <br /> Comments FQ�ei tpi( d,- ' f! <br /> IV <br /> w ii4>w g5/44 'tree 4 � - <br /> Ar,4a,.-;Aoe <br /> Inspection Form Included:O <br /> Comments Included:Q <br /> Business Rep's Signature I Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK T^�i 62081 <br /> �3 EXAhhP LL f 2 3 <br /> White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® ■ <br /> 0723504.0122 <br />