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Waste Tire Su*ey & Inspection Reports Inspection Report Number <br /> �!!lk Slate of California . <br /> CIWMB 181(New Survey Form - Page 1 1 2 1 01 4 7 1 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Co� 7 ,0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> �`��� � P Y Inspector <br /> Physical Address C��� � �►��i D��� <br /> 7 – <br /> t a -TeA–T-0, � �_S <br /> Vo <br /> _21" <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 f � <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O . 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O i • Inactive 0 Truck <br /> I Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> i <br /> i <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler e Tire Derived Fuel <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 ENFQRGEMNT$TA►�`lS _ <br /> V A I HAULING AND MAN(FE8 REQUIREMENTS 0 Noo< <br /> otlOf Ylaletlop 0xtons on <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. COmplianie �Itl9 <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 - Responsible Entities Complying with Manifesting Requirements Data <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 (h7egUlred tArN�lVtfTf `. <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 I 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Rflf6rrld! Ifft�3 <�! <br /> 0 0 14 CCR§ 18461 - Manifest System Requirements for Waste Tire End-Use FacilitiesT <br /> 0 1 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other. § ✓;s fah <br /> Comments Ra// <br /> Ze�, <br /> //1RGJ`7✓c–� �p6� /�!� �/j�l�lall�– a+� lYja✓14 � L►/GIgT� T�YL�� — <br /> a 5!7`� . ` ai, I GJ✓�j crcf.•�� �u6/,7,- /VA� /t�M �en� <br /> 7l'laT !s c a5 a T/� c�c�i✓�� Y 7�f'7 ci ey <br /> Inspection Form Included: 0; – <br /> Comments lncluded: 0 / �5-T6-96 <br /> Business Rep's Signature Phone Number I Ignature Phone Number <br /> INSTRUCTIONS ON BACK Correct: IncorigaS t :lC% _- t 3_��3� 62oa1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />