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i , Waste Tire Survey & Inspection Report Inspection Report Number <br /> St.tCW <br /> B181IN— Survey Form - Page 1 - 1 0 10 7 5 8 <br /> CIWMB 181(New ad/04) <br /> California krtagrated Waste Management Boats <br /> PartA-Surveeeey—_ BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- I ^ Q A - O Inspection Type (fill one) <br /> Site Suffix: ` O( `� 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ^ H Referral,choose referral type(Fill one) <br /> Identifier: v\ Q CHP Q CIWMB ()Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- <br /> Inspected By Inspector <br /> Physical Address - l /Owu. Qse— <br /> Inspection Date 015 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> -_ PM O PM <br /> Operational Status The Typp e Business Role �torage Type <br /> Tire Count(Whole/PTE) t <br /> e (Fill one only) (Fill all that apply) (Fill all that apply); (Fill all that apply) <br /> 0 Active Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude0 Hauler Q Indoor � <br /> 0 0 Inactive 10 Truck <br /> Longitude - 0 Planned 0 OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair fo Trucking Fleet Q Government 0 Retreader 0 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 9 Other �s <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 Entities 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 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 /> 0 1 0 1 Other: § <br /> Comments 1 • dkfeI r <br /> ig was,-ri elects i' ►�e0✓ ftp s rvt• st• . <br /> 5 ieWed. i ar no s eddkd our * soled was <br /> 14o Iafi Imt e Vn l y W k <br /> Inspection Form Included:0� � <br /> ( <br /> Comments Included:Q � <br /> Business Rep's Signature Phone Number6/` <br /> _ for s g ature Phone Number <br /> ■ INSTRUCTIONS ON BACK EXAMPLE 2 2 3 62081 <br /> ©7165 14.0013 White Copy:CIWMB Yellow Copy.Operator Pink Copy LEA <br />