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dWaste Tire Survey $ Inspection Report Inspection Report NumberState CIWM 18 lcrnfa Survey Form - Page 1 { 5 1 01 3 3 0 2 <br /> CIWMB 181(New 04/04) <br /> Cellromla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 7 - O Inspection Type (Fill one) <br /> Site suffix: ' 6 3 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> hiertHfler. O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> G'o,.�1t� A"Itrs <br /> Physical Address <br /> Inspection Date <br /> U�fts— Time In Time Out� <br /> Business Rep TitleQ O O'P'M' O AM <br /> M 2 O0P <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 At that apply) <br /> ' 0 Active Q Passenger ®Generator to Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive a Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (FIR all tttatapply) - <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Govemment Q Retreader p 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 O Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O OIP7RC§ 951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 0. PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O 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 /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 Q 1 Other: § t <br /> Comments4T 6_AS41_ <br /> Inspection Form Included:ZRRU1__P'u. <br /> -L�18'G <br /> Comments Included: <br /> Phone Number, llioeswspffiriPhoneNumber <br /> INSTRUCTIONS ON 14ACK IWIAIM.IPILIEI 11F2 R3 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0603104.0175 <br /> N I F Cir <br /> P <br />