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r;1 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> CIWMB 181 <br /> Survey Form - Page 1 1 2 .- 1 0 1 3 3 1 6 <br /> CIWMB 181(New 04/04) <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: 1 c! l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: S Ek'iV I r Ty Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> r <br /> Business or Facility Name <br /> •� ---�� / Inspected By Inspector <br /> Physical Address <br /> Inspection Date (D3 / / 57 <br /> S Time In Time Out v <br /> Business Rep 2�.� �' + Title S51¢ O AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' J ®Active ®Passenger 0 Generator IS Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility t` <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> ,',>�,fit n.•9�',���,. .."',v.-.�., <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years �.,� ��' • k .��� �� x, <br /> Q Q 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 ti:• <br /> e <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: <br /> Comments <br /> 154-- q Ism tti.3 3S <br /> ( - � gl so ISP �— <br /> _ 4-o r!g - u,_ /Q <br /> Inspection Form Included:Q <br /> Comments Included:Q — zoZ'9K/ <br /> Business Rep's Signature Phone Number Ina tor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ,; Ril _ E X A M P IE! !1-2-T31 <br /> ■ While Copy CIWMB W Yellow Copy Operator P nk Copy LEA ■ <br />