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�t Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of 181( Survey Form - Page 1 14 - 1 Q 1 Q 3 <br /> CBNMB 781(NewNow 84/04) <br /> CelHomfe Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile - - _ inspection Details <br /> TPID- Inspection, Inspection Type (Fill one) <br /> Site Suffix: ' D Lt7 -1 u O ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local r- If Referral,choose referral type(Fill one) <br /> Identifier: SCIAA-, Jp� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name !� <br /> Inspected By Inspector <br /> Ph a resp <br /> 1 j6vf i,+mgz <br /> 7'rae� y 53 O Inspection Date O 2 Q Q / O <br /> Time In \J Time Out <br /> Business Rep /{ ( Titl(e� 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 /> ®Active Passenger ®Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other - <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility J <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 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 /> 0 ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other: § <br /> Comments Rant /j_ I 0>✓(iT1IIh_ l► S (/�'1e. TOiI Was <br /> �s _s_CinlTM hYe GI,%s o fs - vcu lea in cV. <br /> ��-I� I2 4(a z MaVQ QSs P_g R s*V fa)L nwo e_s OF C7L nA�s+s 10 <br /> 2�f1 ioA 1751- s 'D n s3zif ar eac," <br /> Inspection Form Included:0 1 �� <br /> Comments Included:0 1 <br /> Busi ess Rep's SI na Phone Number Ins e s Sr at�re <br /> P 9 P 9 Phone Number <br /> ■ INSTRUCTIONS ON BACK X P I_ 1 2 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br /> 0711604.0152 <br />