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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StCalifornia <br /> is <br /> Survey Form - Page 1 f 6 - 1 0 3 7 <br /> CIWMB WMB 181(New 04104) <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 Q Re-inspection O Referral O Observation <br /> Local ��" If Referral,choose referral type(Fill one) <br /> Identifier: s O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> e <br /> Sla3 °! - ! sI c�e <br /> Physical Ad <br /> re <br /> V <br /> �J <br /> 5/5! SArr(4-' I/Ur " <br /> Swl� ^4 q & Inspection Date O � � � O <br /> fls) 5 2 Time In Time Out IIIVVV <br /> Business Rep n Title �1 ®AM ) ®AM <br /> h l va,4, 0- <br /> OrVI�,S � � � � V O PM � C u 0 PM <br /> tperational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Co t(Whole/PTE) 0 <br /> it Active 0 Passenger •Generator Q Outdoor <br /> O 0 Closed Q Altered / I <br /> GPS Latitude Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — ® OTR I Vr art End-Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> j O Service Station O Hauler Q Agriculture Q Shredder ® Other Sfi i( Man4z�G'!�f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IN R�Al��l�� �CAIIJS <br /> Q `0 _ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 1 <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 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 Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators +�• <br /> Other: § G6 - - <br /> - -- <br /> Comments, ZlJ D N5 fia q �_ o\ , ! la cWi Y1ALA IIJCC.s /I <br /> Tw,SAZfsi mawAdwes stid Wuse <br /> w2S n �e U use <br /> Inspection Form Included:Q ✓ ( . �� <br /> Comments Include .. - — <br /> ss Rep's Sign Phone Number I ctor' S natur hone Number <br /> INSTRUCTIONS ON BACK rr ( '�( �, P L E 111213 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0 t'-.1_5 1 1714. 0 7 15. <br />