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t„ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California <br /> CIWMB 181(New 04M) Survey Form - Page 1 19 - 10 13 2 31 <br /> Callfornla Integrated Waste Management aoerd <br /> Part A-Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection n ^ - Inspection Type (Fill one) <br /> Site Suffix: o+ ®Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: \Int Il, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A q _Trv_4usfres3 0 1a�fLFa�-fz� 9 - l I <br /> Physirhl Address f <br /> I I o .�' . �ck.w(al_pq NOL r� <br /> Inspection Date C ;L / 05 <br /> Loa,( 95AI 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �J ta�� Q _ ,• J� �Y � O PM 0 PM <br /> Operational Status The Type Business Role Storage Type . <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> r 10 Active ®Passenger A Generator 0 Outdoor <br /> O O Closed 0 Altered A114 <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 inactive ®Truck <br /> Longitude — O Planned ®OTR O End-use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler O Agriculture 0 Shredder ®Other QCf �Qu(13yytQ{ �SC {�$/ <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires r" <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. "y <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements s <br /> O 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Fortes and Tire Trip Logs for 3 years <br /> 0 Q <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers �� 7, �� _ �• <br /> O <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities �•' � •. � •-s.��`�"-�*v` w��„ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 10 1 0 1 Other: § <br /> Comments R o 5 e llwi W no ire <br /> are 6L(ikiew oAlk p mto mad4li2lr , N( wast e <br /> T)rz vendor i sVilStCnot <br /> Inspection Form Included: <br /> Comments Included:0 _ � C <br /> Buell s Rep's Signa ure hone Number M a or's Miniature Phone Number <br /> INSTRUCTIONS ON BACK a X + M P L E 1 3 62081 <br /> •:,' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ■ <br /> A 7 n59A4.0334 <br />