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= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of 181 N. <br /> Survey Form - Page 1 1 1 • 1 Q 1 3 3 6 4 <br /> CIWMB 181(New 0 age <br /> Calf/omis Integrated Waste Menagament Board <br /> Part A-Survey___- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> She Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cj r��p,�QI L� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name y <br /> Inspected By Inspector <br /> Physical Address /0 lvr+ i�G1GG S <br /> �33fl Imo► Ad A-4-- 124 <br /> C�7 q5�8, Inspection Date 0 1 / 2- 6 0 6 <br /> Time in Time Out <br /> Business Rep Title O AM 0 AM <br /> O PM 0 PM <br /> �oL <br /> - i Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I '(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger S Generator ®Outdoor <br /> O 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 /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet ®Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel I <br /> I <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 <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 Entitles 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 1 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 Other: § <br /> Comments a►.)��'s_ � Qr''fi>r`rLee. �/� r�����s rrS <br /> -_ 2- <br /> 'Inspection Form Included:0 00, Ll <br /> Comments Included: - �49f <br /> I ass <br /> j;, Signature Phone Number I ector's Signature Phone Number <br /> INSTRUCTIONS O ACKE )( A M P L E 111213 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0605204.0538 <br />