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Waste Tire Su- -%y & Inspection Report Inspection Report Number <br /> Slate of Californi <br /> CIWMB 181(New 0a 4104) Survey Form - Page 1 16 - 10 14 7 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Proflhe Inspection Details ! <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local j If Referral,choose referral type(Fill one) <br /> Identifier: �nrAk `.f-y 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / <br /> Inspected By Inspector <br /> ' t5 1-'10 <br /> Physical Address 3 y - / 0 ( q ►� �� �5' <br /> �y�y r- <br /> � t Inspection Date / / -2- -2- <br /> Time <br /> Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> iO PM Q 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 /> } 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 1*Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer • Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Disrnantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOR001MON <br /> 1l M ►tt 4N4 kND I4EQUI CEMENT$ 0:N4tiets iQf y19 � <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O 0 PRC§42956-Registration/Decal in Vehicle COttlplh[t1t � � '/''� <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days f �ui ' l '� <br /> 0 0 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 /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities1 IR <br /> 0 0 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators ..,' / !;. <br /> Q M <br /> 0 0 'Other: § i ;% ' r11� <br /> Comments ) l l- // Wr�E'c,tC/�n o V <br /> r�S � t7 47� <br /> �p/e.-,�h�n,•s _ -� �/J-r"D [ �/ 1-7 9 2 4 -U [ ��'S' W M o b d e_ 4 <br /> a `Sv �c:5 -'�''�%S gc+CcQi�sS 1 r57"e-z.Q ei5 G; tv1G;c:r1— �+� 6i►sr'+tief35'.. <br /> Inspection Form Included: Q! <br /> Comments Included: 0f <br /> Business Rep's Signature Phone Number r' ignature Phone Number <br /> INSTRUCTIONS ON BACK IEAW p L � <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />