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=L[ Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWM 181(New <br /> Survey Form - Page 1 6 -- 0 3 7 G <br /> CIWMB 181(New 04(04) <br /> Callfornla Integrated Waste Management Board <br /> Part A_Survey _ BLUE OR BLACK_INK_ PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� � � � � - IJ / Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q 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 Inspected By Inspector <br /> Physical Address <br /> Inspection Date ! 3 06 <br /> , �,4 95�3ao <br /> Time In Time Out <br /> Business Rep Title o r O AM2 O AM <br /> ® <br /> PM D V 0 ®PM , <br /> - - <br /> Operational Status Tire Type ype Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 1 n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ` V <br /> ®Active Q Passenger ®Generator @ Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude _ Q Hauler Q Indoor <br /> 0 Q Inactive 0Truck <br /> Longitude - Q Planned Q OTR Q 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 FacilityQ. <br /> Q Q 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers ym <br /> atW. a <br /> Q Q 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 <br /> Q Q Other: § 7 '} ' <br /> Comments RD" f6'ie iA5,oQc ion AzsdAm , "-e- -Foh JI" -- -cal . <br /> ha5 a-proxifti"�r.P /DID ksed Gt,t25� c Art's on .fie.._ � ar-e �✓+'Ced h <br /> Goy Tires. ar�i� s�nd9i 0-4, Vt� ex' cccKS `� <br /> c�A af- 4At6_+i <br />