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,ro <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> rr CIWM 181(ornla Survey Form - Page 1 19 . 1 0 1 3 6 7 7 <br /> CIWMB 181 tew 04104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 9 70 7 7 0 Routine ORe-inspection QReferral <br /> Q Observation <br /> Local / // _ / If Referral,choose referral type(Fill one) <br /> Identifier: �L o/�J2 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — - - <br /> Inspected By Inspector <br /> fit'- i'-62- z ke3 q - o / S((¢*iA4� <br /> Physical Address <br /> 7s5- . , - <br /> r �5�3 Inspection Date <br /> Time In Time Out <br /> Business Rep Title/�J g i AM n 0 AM <br /> 0 PM fes' 9 / O PM <br /> -- -- - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t ' ® (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active Q Passenger •Generator *Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive *Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 ENFO CEMENTSTATU ' <br /> t5 F REtC ..... 'C <br /> 01N"'�xi' <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transp0 of Tires Nut)ce Of.-Violation Q_Exfension <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. ComPliar)cat Deadldne <br /> Q Q I PRC§42956-Registration/Decal cE ti Vehicle <br /> O O 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 L-- <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days j equrred fCr NDV or;EX77 <br /> -.fa <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> r. � - <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> O O Other: § <br /> Comments %�lJuyZtE itzA ?�st �LCi r GClzy 7 /_ <br /> Inspection Form Included:Q <br /> Comments Included: <br /> BusMess Rep's Signature Phone Number lnspector's,Signature Phone Number <br /> INSTRUCTIONS ON BACK i JEjXjAjMjF1L77E1iT2N 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> Alt_.24904.A 1 :4 <br />