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= Waste Tire St <br />Ill State of California <br />CIWMB 181 (New 04104) <br />California Integrated Waste Management Board <br />Part A - Survey <br />Business Profile <br />TPI- <br />Site ` / <br />Site Suffix: 1 P <br />ey & Inspection Repo Inspection Report Number <br />Survey Form - Page 1 15 -1 01 4 7 2 1 <br />BLUE OR BLACK INK PEN <br />-7'5 - o <br />Local <br />j Identifier: <br />Business or Facility Name <br />Wj'S <br />Physical Addr <br />2,9 a N <br />Lok; CA -5�Sa,!4 o <br />1 Business Rep Title <br />Tire Count (Whole/PTE) Y <br />� s <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler Q Agriculture <br />Inspection Details <br />Inspection Type (Fill one) <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By <br />Inspector <br />Q Government <br />Q Retreader Q Dismantler <br />Q Collection <br />Inspection Date <br />p <br />I D I <br />p <br />Time In <br />Time Out <br />O AM <br />O AM <br />O PM <br />O PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(FA all that apply) <br />(Fill all that apply) <br />10 Active <br />+♦ Passenger <br />0 Generator <br />Q Outdoor <br />O Q Closed <br />Q Altered <br />� Q Hauler <br />Q Indoor <br />Q Inactive <br />0 Truck <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Ill Container <br />Q Government <br />Q Retreader Q Dismantler <br />Q Collection <br />Q Crumb Rubber <br />Q Shredder <br />Q Other <br />Q Tire Derived Fuel <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility, ENFORCEMENT STATUS,,. <br />V_ j Ai j HAOLING ANO MANIFEST REQUIREMENTS 0 Notlil Of Ylcglation Q Extension <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliance Doadllne <br />Q Q PRC § 42956 - Registration/Decal in Vehic)e <br />Q 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date m <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requlrei3t'orNC1VOr>rJ(7) <br />Q <br />Q 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years T <br />Q 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers Q Referred tCI11YMi ,infOCopXt1,1gt <br />C) 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 Q 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />-� En Oprnpit�rt�+p Ma�ltlftl�tft��� j 'J; <br />0 0 Other: <br />Comments A0 til /'15�C'G778✓1 <br />Vlolq17IIA4S a r` 4e-o� 6n <br />Inspection Form Included: 01, <br />_ <br />Comments Included: Q� <br />Business Rep's Signature Phone Number s Phone Number <br />INSTRUCTIONS ON BACK correct.0 Incorrect; C .X R h�t� PT (rL� 1�� 62081 <br />1' White Copy: CIWMB Yellow Copy: Operator Pink Copy. LEA <br />