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Waste Tire Survey & Inspection Report Inspection Report Number <br /> State u� <br /> CIWM 181California Survey Form - Page 1 I $ - 1 0 1 4 8 8 0 <br /> C1WM6 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> _Business Profile Inspection Details <br /> TPID- � � � � Inspection Type (Fill one) <br /> Site Suffix: I 1 Q Routine 0 Re-inspection 0 Referral o Observation <br /> Local • If Referral,choose referral type(Fill one) <br /> IdenNtler: 5et— .�Oc,���.�►-. �r�yf(U Q CHP Q CiWM6 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> S J t;'t,✓ct 6 I,,•� '1 I O �' �z <br /> Physical Address <br /> A c, <br /> Inspection Date � � ! f � ! c) S <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> r O PM O PM <br /> r � � Operational Status', Tire Type Business Role i Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger Generator ®Outdoor <br /> � • 0 Closed Q Altered <br /> GPS Latitude If Hauler 0 Indoor <br /> O Q Inactive •Truck <br /> Longitude – + 0 Planned Q OTR i 0 End-Use 1 ®Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Q Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler 0 Agriculture Q Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORGEMENT STATUS <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires (( YIOw111411, nsiob <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. f � <br /> Q J Q PRC§42956-Registration/Decal in Vehicle i <br /> 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements / IJ <br /> 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 <br /> O O <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 r�� '' r <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities " <br /> 0 0 +14 CCR 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 o I § y Q =- <br /> 0 0 Other: § <br /> Comments ,HA Ih[PY' a . %. T <br /> 931 <br /> -2,j je,1ds . d>b`t-9 -7 el- <br /> -2 <br /> Inspection Form Included: 0 <br /> Comments Included: 0 — — ___ __ _ ` I _ <br /> in Rep's Signature Ph ne_Number lnsp 's Signature Phone Number <br /> / <br /> viyy�v/ y / i 62081 <br /> INSTRUCTIONS ON BACK ._^ � ��f z E:?� A<Ihh P L E t21 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />