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u:_ ■ <br /> � «;3 Waste Tire Survey & Inspection Report Inspection Report Number <br /> staft CrAIM81811(Nmis Survey Form - Page 1 11 - 1 0 1 3 6 4 5 <br /> CNVMB 181(New 04!04) <br /> CalflorMe Integrated Waste Manaasment Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Detalls <br /> O <br /> TPID-ffi2 / I Inspection Type (Fill one) <br /> Site Suffix: 3 0 o o 0 Routine Q Re-inspection Q Referral 0 Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: Sz,%_ r/pa�f�,y (�E7e:tn j O CHP 0 CIWMB 0 Complaint O Educational Visit Q Other <br /> Business or Facility Name OO 6� <br /> Z.--,, Inspected By Inspector <br /> Few Z X <br /> Physical Address <br /> 93s Ar /0-- <br /> Inspection Data 0 7 <br /> Time In Time Out <br /> Business Rep Title / 0 0 AM 0 / 1111111 AM <br /> O PM 0 PM <br /> f/ Operational Status Tire Type Business Role Storage Type <br /> D (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r 1 j <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler IS Indoor <br /> O Q Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service station 0 Hauler 0 Agriculture Q Shredder !Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days <br /> O 0 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 /> O 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 /> Q Q Other: § <br /> Comments <br /> Aldi Pi-Yy <br /> i,(Jt vL,7�J and D� �U/ 4n c��eQ'' �s%cS. C' %G s yi'tcro�� <br /> o � a <br /> Inspection Form Included:O <br /> Comments Included: Business Re 's nature Phone Number Inspector's Signature`) Phone Nu bl <br /> INSTRUCTIONS ON BACK `XjAAAPLE 123 62081 <br /> ■ While Copy:CIWMB Yellow Copy Operator Pink Copy:LFA ® . <br /> 0622104.0013 <br />