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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CrWM ..181(Nrnla purvey Form - Page 1 ( 0 2 5 $ 3 0 <br /> CIYYM9 181(New 04/04) <br /> callfornla Integrated waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection� � � _ D ` Inspection Type (Fill one) <br /> Site Suffix: <br /> Q Routine Ig Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � L � Inspected By Inspector <br /> dw <br /> Phys�at Adress `f cy„sj Q 9 FrwL,,vo-Y-L <br /> _ <br /> _ Inspection Date <br /> l o I o <br /> Time In Time Out <br /> Business Rep l C Title Q AM - O AM <br /> ✓�p�,� 1M+�►� M''' , O PM - t� PM <br /> IM <br /> V t <br /> Operational Status Tire Type I Business Role Storage Type <br /> Tire Count(Who�e/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active -@15P�assen er ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use I Q Container I <br /> I I <br /> Business Type (Fill allilthat apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 (f Other <br /> Part B-Inspection of Waste Tire Dealer, Generator Hauler and End-Use FacilityVV <br /> , txNPORCEM NT STATUS _.---•-. _.--_^ <br /> 4A -aN3` NF]MA'fF $T.RRQU-11REMENTB <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Ci�',tticta ibig tlpn Q Extenalon <br /> QQ PRC§42953-Contracts with Registered Waste Tire Haulers. +;;ilttt�Ii�In.49.,_ hd)InA <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> _I Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements J <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days f�e4u d forNQV.a°EXT) <br /> Q ; O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> r i <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �@� �pfAl'g�ftlt►r1t i <br /> y .,f <br /> Q O 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators "mss �i sty f < <br /> Q Q Other: § ;":gN• , 1t111 `-•^ ._ <br /> Comments <br /> k <br /> Stx-ter, C-�¢lrtr- <br /> co<c-<.f� <br /> Inspection Form Inclu ed: Q <br /> Comments Inclu d: Q - <br /> uslness p's Signature Phone Number AInspor's Signature Phone Number j <br /> INSTRUCTIONS ON BACK p1�� EFTI 62081 <br /> Enterer :. —[� _ <br /> KB While Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />