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eat <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> t� <br /> State MB181dNew Survey Form - Page 1 I 3 J $ <br /> CIWMB 181(New 04/04) <br /> califomla integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Buslness Profile Inspection Details . <br /> TPID- tJ g S _ Q / Inspection Type (Fill one) <br /> Site Suffix: i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: e,�a +�h Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> BusinessorFacility Name / _• Inspected By Inspectof <br /> Physical Address - 6 / S,4,4AV—, A,-)"4A <br /> �0,�-'� /rr- '��'F��,�.Q•`9 [ter.'`� - <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title AM is AM <br /> / / o 1? O PM I � 30 O PM l <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole[PTE) / o0 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active ®Passenger ®Generator 40 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> •Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility "bVt 3RC7=MENf STAT-US_._ <br /> V •"'A =HAULING AND MANIFEST kr=0Ukiff?lIf=1Vf6'> <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension i <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. wCainpliance Deadline "f <br /> QQ PRC§42956-Registration/Decal in Vehicle LL <br /> — } <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements �.Date / 1 <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB - �T�� ;r <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requrr d for W1C1rEXT) ` <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities p <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators E' <br /> ftca- No YjnE4flot� <br /> Q Q Other: § kn N w ,sv r. <br /> Comments <br /> o,/ i.y <br /> lid/ •mac X,-,Ze 4ve <br /> Inspection FormIncluded: <br /> Comments. Included• <br /> Rep'signature2;� Phone Number Inspector's Signature Phone Number <br /> O <br /> INSTRUCTIONS ON BACK kF & � A4 M P � 62081 <br /> White Copy.CIWMB Yello:v Copy.Operator Pink Copy:LEA <br /> 4 7 0 4.l-1*_2 7 4 <br />