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zlE , Waste Tire Survey & inspection Report Inspection Report Number <br /> State of <br /> C1WM 181Survey Form - Page 1 15 - 1 0 4 7 3 8 <br /> CIWMB 181(New04/64) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier fi t0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Qr JOtiq uf►� +n r- <br /> Business or Facility <br /> lIName 1" Inspected By Inspector <br /> Physical A ddr ss'R'rX <br /> i <br /> L_oe Inspection Date Cf <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> I Operational Status i Tire Type Business Role Storage Type <br /> Tire CountWhole/PTE , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` 0 Active 0 Passenger i 0 Generator Outdoor <br /> O * Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ®Truck <br /> Longitude 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 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 ENFORGEMEN?°STATUS: r'y <br /> V- A HAULING AND.MANIFEST REQUIREMENTS <br /> 0 Notloe:Qf Violation (��xtf►x���s 1 <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires f <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> ;r <br /> O O § 9 i Comptlenc� Dtillne <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 Tri Logs within 90 days (Rettull�rffitlTN1�1 ,�/"'��� <br /> § P 9 <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 O �� <br /> 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 ( Fkt 01 w <br /> 0 0 Other: § <br /> Comments 5 j v)p ! 5e,��$ '�I`&5. j t ,tr,_ <br /> V)A-a_ T)re-_5 V y L151 v-_R [� �w l e�C j X15 r 'iY-� jj,1 ,l ty— <br /> Inspection Form Inclu : 0 <br /> zxv, 2j <br /> Comments Includailko - <br /> Busin s ep's Signa ure Phone Number In ector's Si nature— Phone Number <br /> INSTRUCTIONS ON BACK Coflrb f •1n00"0. �?� E.X AA PI lr E Y 2 3 62081 <br /> White Copy:CIWMti Yellow Copy:Operator Pink Copy:LEA <br />