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Waste Tire Survey & Inspection Report Inspection Report Number ■_ <br /> SM Ot181(Nmia Survey Form - Page 1 17 - 1 0 4 6 3 $ 1 <br /> dWMe 181(New 04104) <br /> Ceilromle Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A-Surve/ _ - <br /> Business ProfHe Inspection Details l' <br /> TPID- I / _ O Inspection Type (Fill one) <br /> Site Suffix: , 3 b (� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � �N� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Phy Ical Address <br /> �z3`7 � Nwy z6 <br /> Inspection Date / f <br /> Time In L r Time Out <br /> Business Rep ✓ n Title O AM / 0 AM <br /> 40^�r't /�^c�^- PM O � ' / � ®PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) _ , / 50 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> O Q Closed Q Allered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 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 0 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 Facility <br /> Q I 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 <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest Svsi&Q4Wa ers or Waste Tire Generators <br /> Q Q 1 Other: § fLl /�T1�h D►+� l J 1 <br /> Comments Prw <br /> V+' <br /> q ot- t,.a:� -h;� 5-� A a-�►�.e._ —fin rte? <br /> D D►— <br /> Inspection Form Included:Qd <br /> Comments Included:Qs ne - lJ <br /> ss ep' Signature Phone Number Ins or's ignature Phone Number <br /> INSTRUCTIONS ON BACK I E IX rA IMI P 'L E 1 2 362081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0533504.0037 <br />