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aea <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rr i <br /> State Of California Survey Form - Page 1 7 • d <br /> CIWMa 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection DetaNs <br /> TPID- 0 3 5- - D ' Inspection Type (Fill one) <br /> Site Suffix: / ®Routine QRe-inspection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 'Sa1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - - <br /> Inspected By Inspector <br /> Low *oUA-, <br /> Physical <br /> lA,dddrrres�s � � - / � ( Qr" <br /> L <br /> 1 od,L lL�0 / g5,;?Lfc) Inspection Date © 3 I 0P / 0 <br /> Time In Time Out <br /> Business Rep / Title O AMQ AM <br /> O PM O PM <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 /> Active to Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler I*Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 ®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 F <br /> Q `O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <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 /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days =r' <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-Manifest System Requirements for Waste Tire End-Use Facilities M <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators w ' . <br /> Q1 Q Other: § �' <br /> Comments ' ` �„� . - /D <br /> AARWird Aj O N, bc a c <br /> Inspection Form Included:Q! �g.atui <br /> Comments Included:Q Businss RPhone Number In a or's A n ure Phone Number <br /> INSTRUCTIONS ON BACK a; F E X AIM PI E I 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0705104.0057 <br />