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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> C`a`se,CaliforniaSurvey Form - Page 1 1 6 . 1 0 0 6 4 5 5 <br /> CIWMB 181(Naw 04/04) <br /> California Integrated Wast.Management Board <br /> Part A-SurveyORBLACK OBLACK INK PEN <br /> Business Profile Inspection Details - - <br /> TPID- 2 � t4- <br /> _ O t Inspection Type (Fill one) <br /> Site Suffix: J :/ L+ ( ! 0 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 r, <br /> Inspected By Inspector <br /> O I wri c S <br /> Physical Address / <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> O <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that appy) (Fill all that apply) <br /> r ®Active Q Passenger •Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler � ®Indoor <br /> O Q Inactive ®Truck <br /> Longitude - End-Use Q Container <br /> Q Planned Q OTR Q <br /> Business Type (Oil 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 Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle ; s <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 /> 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 ` <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities ` ` z � <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' <br /> Q 1 Q 1 Other: § L �+_ <br /> Comments 1 � wR w�S �St e! �\w-F- T1Y _, i)r rww •'t[[� <br /> , <br /> � -f-i•-mss ?�s�,lt,� �I'P�1� 1 c�z���-- Si=d�g o^� <br /> u -* T o,.5 CI wm aa- —�� -- 6•-oGdr� <br /> Inspection Form.Included:Q <br /> Comments Included:-0 <br /> X68-V 1(6 <br /> - <br /> usiness Rep's Signature Phone Number oes Sig ature Phone Number <br /> INSTRUCTIONS ON BACK �a :1 sP 3 62081 <br /> 1�—� „ A, rlltt <br /> ■ White Copy.CIWM8 Yellow Copy Operator Pink Copy:LFA, ® ■ <br /> t_1 7 0_59 914.0'4 r, <br />