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i� Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stat 8181of l(New Survey Form - Page 1 l - 1 01 419 Z <br /> CIWMB 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 Inspection Type (Fill one) <br /> r L '--7 <br /> Site Suffix: D `i / 3 &Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> a&.— <br /> ��� �r`' iQ CHP Q CIWMBQ Complaint Q Educational Visit Q Otherbusiness or Facility Name ` <br /> nn Inspected By Inspector <br /> Physical Address r sem``` <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title - O AM - O AM <br /> Q PM O PM <br /> ti- — 44a �7 V`("y— <br /> ��h 19A,� f i.Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) © (Fill one only) (Fill all that apply) (Fill all that apply) (Fill ail that apply) <br /> f f Active ® Passenger ® Generator ® Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler � Q Indoor <br /> O Q Inactive I Q Truck <br /> Longitude — I + O End-Use Q Container <br /> Q Planned Q OTR <br /> I � I <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 /> 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 �kwasol AN $TATUS <br /> O sr>�n�ajs . <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ,, / ° � , <br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle ,; r <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements ' <br /> 14 CCR§18459.1 (a)(b c)-Tire Program ID Number from CIWMB <br /> /�•/ice/„%w <br /> Q O 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 /> O O y y. _�7 <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers ; `, <br /> Nrii� yi <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> OO 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators -z <br /> O O Other: § - <br /> Comments <br /> le, <br /> �n r <br /> �,ia., �Y�.�� d S-- O!3o J^'1-�hl'�'-s'it- <br /> l(fblt�5-,� rel”' urq��[-!`�c�s . <br /> Inspection FormIncluded: Q Q <br /> Comments Included: Q <br /> 1 Buslneature Phgne Number specter's Signature Phone Number <br /> — - — °,--WN-0 <br /> 62081 <br /> INSTRUCTIONS ON BAC . 7.y//� I 1 r`f }�i 'y/i%J,"I <br /> ;'.' >.i'.1 b L L a� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />