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rt, <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> r State of California <br /> CIWMB 181(New04/04) <br /> California Integrated Waste MManagement Board Survey Form - Page 1 1 2 - 10 1 3 4 0 7 <br /> Management <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> . i I - Inspection Type (Fill one) <br /> Site ffi <br /> Site Suffix: / 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: sa(1 JQG..p(,iti�) C — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L1 S VUwaY <br /> S-'�Jvl �'L�` ckfz) n ^, Ll 5�Lo(P <br /> Inspection Date + 0 O <br /> Time In Time Out <br /> Business Rep Came I Title a 0 AMQ / 7 O AM <br /> r,a(,e i ® PM ®PM <br /> -- - ���— Operational Status Tire Type Business Role Storage Type <br /> Tire Count(W hole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 ®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 ®Other ftiC� T <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q 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 /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1010 1 Other: § <br /> Comments o lie l n rJ -Ki S claq• 1 t'ltL fo ,.q w,5 f 1 0 <br /> (usesran�a►-�7Ire -QrVii:e :t dC��e o� r� aKd ryris�e � fins � J <br /> eS oh si.+e are m* A&16 ie-' o-,Ad 10 are +was .fir m <br /> 412pal r e i Lkilas vigided, A/") VID 'flillS', <br /> Inspection FormI /ncluded:'Q �,�2� 1.K ^9 V, <br /> Comments Included:Q Q�(Q �((,(�( -'`� <br /> Business Rep's ISIgnature phone Number Insobetor's 4ig Phone Number <br /> INSTRUCTIONS ON BACK �I 'fr FE"PILIE1 113 62081 <br /> ■ White Copy CIWMB Yellow Copy Operator Pink Copy.LEA ■ <br /> 060Clf5A4.0212 <br />