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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ■ rr Statee,l:a"`orale SurveyForm - Page 1 1 3 - 1 01 3 5 7 2 <br /> CIWMB t81(New OMB6) (�I <br /> Geromla Integrated Wa.te Management Board "�' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- ++ (� 2 (� Inspection Type (Fill one) <br /> Site Suffix: l 0 5 ,3 Q I 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �`� If Referral,choose referral type(Fill one) <br /> Identifier: �1 LNt�rl O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> Colt COU4�CIQ <br /> Physical Address 3q <br /> 35l( MLvo-tDn <br /> S1 ZCk;f0vj ^/QInspection Date C) I 1 <br /> i, I�iJ Time In Time OutJ <br /> Business Rep &C L •+ ,�,,�(�n Ie O AM O AM <br /> )rad Wr vi O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 �., (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r o'-'L/ ®Active Q Passenger Generator Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive O Truck <br /> Longitude — Q Planned 1 0 OTR O End-Use ontainer <br /> Business Type (Fill all that apply) <br /> O 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 O Crumb Rubber {_ <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 OtherV <br /> Part B-Inspection of Waste Tire Dealer,Generator Hauler and End-Use Facility 1N7 OR Et�7 S3iAlt)5 <br /> z�t " Notice Of Vloiatroq Q Fatfensrt�t"n <br /> QM Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires r <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. nmpliance DeadfNtq ry <br /> O O <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements XJiitte <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB a r <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments S ) kin P, /r1l <br /> I�ncn ' r�. ase oF� - Y -- d s z CTLs v,v�r <br /> i/ (D s :"r 3�'j* til - -.� , LGtS� C .� 't: iriCll l�ltr4Ct(Esr- Q[ j afCL?2� <br /> _ - -- �- �S <br /> Inspection Form Included:0. <br /> Comments Included:0 s1� _G1i <br /> Ines ep's Signature Phone Number In or's lourfil PhoneNumber <br /> INSTRUCTIONS ON BACK 0 A M p E 2 3 62061 <br /> ■ White Copy CIWMB Yellow Copy:Operator- Pink Copy.LEA ® ■ <br />