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ere <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB <br /> (Nrnla Survey Form - Page 1 1 5 - 10 13 5 0 0 <br /> CIWMB 181(New nage <br /> Call}omla Intogratsd Worsts Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalts _ <br /> TPID- Inspection/ - / Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral O Observation <br /> Local n If Referral,choose referral type(Fill one) <br /> Identifier. b '?e.o 0 CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> oix!r kyr+Vie! 3 9 - � 0 � S •9{7i 4 <br /> Physical Address ��6,07;41, <br /> Inspection Date <br /> Time In v Time Out <br /> Business Rep Title D A AM / AM <br /> O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (FIB all that apply) <br /> Tire Count(Whole/PTE) <br /> 0 Active 0 Passenger 0 Generator Q Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude � Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder S Other �� <br /> PartB-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> I <br /> 0 Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires i l' <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0. PRC§42956-Registration/Decal in Vehicle <br /> 0 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 /> 0 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 Q 1Other: § <br /> Comments ,"e,2.4 /hf i� r1 Q/ ���/ Rae KW&4"v.'-bp <br /> FaeJ�`f�lrs �ilcRcp�� �i/e /acc�f»e cvgf� 9Gi^e!�, G%L '.s <br /> l�iewp�! �e osv rpg!.4� ,tC y &,ZZe�14,,0 cow AR_ S <br /> i Ce !!4 /o <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Busine ep's Signature Phone Number. Inspector's Signature Phone Number- <br /> INSTRUCTIONS ON BACK !: A M P L E' 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0618604.0095 <br />