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eoo <br /> Waste Tire SAey & Inspection Repo Inspection Report Number <br /> State forna <br /> CIWM 181 loon Survey Form - Page 1 i t - 1 0 4 $ 3 0 <br /> CIWMB 181 New 04104 <br /> California Integrated Waste Managemont Board <br /> Part A- Survey- BLUE OR BLACK INK PEN <br /> Business Profile Details <br /> TPID- r Inspection Type (Fill one <br /> Site Suffix: ` ® Routine O Re-inspection O Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP O CIWMB 0 Complaint 0 Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical"Add Cress - <br /> t o u <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title_ O AM Q AM <br /> O PM QPM <br /> -- — — 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 all that apply)' <br /> Z" `� I4 Activetl� Passenger ®Generator ® Outdoor <br /> - -- — -. _-- —_ O Q Closed Q Altered <br /> GPS Latitude Q Hauler O Indoor <br /> O I Q Inactive Q Truck <br /> Longitude - O Planned L0 OTR � 0 End-Use <br /> L0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer (: Auto Repair Q Trucking Fleet Q Government C)Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body © Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> e<, ../ � J , / J - ;:x-: ;1:., "`%' ;/j iii' �.��"�s ,.✓//i:!//i�/i�?Ji,:"i'{'x%/;i%i�/,;�://k'".'r .�,i% <br /> j,�/i E ' �;�y� '"ii(/i:^y;ai;%<_;,,;./�%/Hi�%��/,iii;�/fj,.✓%Ji .., ,i,: �,n..y 2•ia%:,,u.�,:,/.� i//��S / „/%i% <br /> O r O PRC§42959 -Waste Tire Hauler Registration and Transport of Tires ;i <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. / ,,•r'�� j: j <br /> Q PRC§42956-Registration/Decal in Vehicle hui. ' �/ '• '�/j. <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements j f <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 <br /> 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 /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities f/ <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> f/ r <br /> 0 0 Other: § <br /> Comments ��y _�_W�sr��- - ' in,�c�S� �, .N`.c•J� ��i:.f/� t4'`� 7-�- �-�� <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> - S slness ep s S gna ure Phone umber ' re Phone Number <br /> Insp tors Signature� � — <br /> `' 62(781 <br /> INSTRUCTIONS ON BACK EINiIqL L �-L2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />