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■ ;a Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> .' State of caltfomla <br /> CIWMB 181(New 04104) Survey Form - Page 1 f 9 - 10 1 4 0 81 <br /> California Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection.Details <br /> -- — <br /> TPID- / 7 � ,f- <br /> f `2 - Inspection Type (Fill one) <br /> Site Suffix: ` t <br /> ®Routine Q Re inspection Q Referral Q Observation <br /> Local � �L If Referral,choose referral type(Fill one) <br /> Identifier: �(aar Nt �J �-'J <br /> _ f: .-___.__ ,y � _�1b Q CHP Q CIWMB Q Complaint Q Educational Visit.Q Other <br /> Business or Facility Name 7—�_ Ins acted B <br /> gc.' <br /> � P y Inspector <br /> PhysAddress _. <br /> 3 G1 l <br /> Inspection Date QI -7 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> of rl t�o1 `r 6 erationai Status Tire Type Business Rol pe <br /> O PM 0 PM <br /> P yP a Storage Type <br /> (FIII one only) (Fill all that apply) (Fill all that apply)Tire Count(Whole/PTE) ppy) (Fill all that apply), <br /> r. ' "� ®Active ®Passenger ®Generator ®Outdoor. <br /> GPS Latitude D Q Closed Q Altered <br /> 0 Q Inactive Q Truck Q Hauler Q Indoor <br /> Longitude - <br /> • Q Planned Q OTR Q End-Use Q Container <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 /> 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,G({yyjeneraaatt�uor Hauler and End-Use Facility <br /> vno7. it"^-J�3z'��.�I�Hy �� 1J-.:•'A�4Y` �yeW+:A- .O'��.'�..d� 'F+G� F� 3 e�y��.C't« � <br /> ty�'�. <br /> Q Q 'PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. t <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> �r <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1(a)(b)(c)-The Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days s3 , <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 <br /> Q Q 14 CCR§18461 ManifestSystemRequirements for Waste Tire End-Use Facilities „ <br /> a <br /> Q Q. 14 CCR§.18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators- <br /> Q 'Q �Other: § x <br /> Comments <br /> - <br /> n <br /> Inspection Form included:Q - <br /> Comments Included: y77 9aGxa <br /> usiness Rep's Signature Phone Number Ins c or' ignatur <br /> ■ r 2 Phone Nu <br /> mber <br /> INSTRUCTIONS ONBACK 62081E X jp $ <br /> ■White Copy:CIWMB Yellow Copy:Operator .Pink Copy.LEA <br /> 0526204.0355 <br />