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tis <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California � <br /> CIWMB 181(New 04104) Survey Form - Page 1 16.- 1 0 0 6 6 2 9 <br /> California Integrated Waste Management Board - - - -` - - - - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Busyness Profile.- _: Inspection Details__ <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: I, L\ tai I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ) If Referral,choose referral type(Fill one) :.. <br /> Identifier Q v\ o q�T.,(,�Ov` �Lk VV� Q CHP 0 CIWMB Q.Complaint. 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date C> ® <br /> —_, Time In Time Out <br /> Business Rep Title i O AMrr�, 0 AM <br /> 1*PMM <br /> v c \ rZ `� <br /> IIx v� <br /> — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply <br /> Active 0 Passenger ®Generator Q Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> o Q Inactive Q Truck <br /> Longitude — 0 PlannedQ OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture Q Shredder if Other 7;1" <br /> Part B-Inspection.of Waste Tire Dealer,Generator.,Hauler.and End-Use Facility F <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. " 1` <br /> PRC§42956-Registration/Decal in Vehicle b <br /> Q 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 4 �, <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 /> ✓u4.y <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities s x <br /> 0 0 14 CCR'§18462.Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> _ .. <br /> 0 0 . Other: § 5 <br /> Comments <br /> VA <br /> Z5 to D .e <br /> Inspection Form.Included: (� d <br /> Comments Included.Q G <br /> Business Rep's Signature Phone Number I peetor. fgnature Phone umber J <br /> — �c�-a k•gay, 62081 <br /> INSTRUCTIONS ON BACK ,.�� ,. z. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0525804.0135 <br /> FILE CAPY <br />