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� ,. Waste Tire Su. :y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWM6181(New 04/04) Survey Form - Page 1 l 4 10 0 8 0 3 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f f Q — © j I$Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> iInspected By Inspector <br /> Physical Address <br /> ' / ^4t ��-�Q Inspection Date © 7 <br /> �J Time In Time Out I <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> 0 Active 41 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered I <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 &Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer • Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT_SF�TS <br /> V A 'HAULING AND MAN)FEST REQUIREMENTS 0 Notice Of. Vlalstian Q i;xt$ntslon <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. COnlpll [!Gq I�@dlftlp <br /> 0 i 0 'PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date l l l I <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from GW MB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days f 'ear�lleg(Y4J N�rAI' T)' <br /> 0 I 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 (� �T�Ifl3TtAd l }tl ��Ef �i� <br /> 0 0 14 CCR§18461 Manifest System Requirements for Waste Tire End-Use Facilities ' <br /> 0 1 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' / / , /✓i , <br /> 0 0 i Other: § �`' J ` (} L_=_ /(.��...... i%i''/%��,/�S'i��i�-� �///.✓// <br /> Comments <br /> CA t->i1o�� <br /> C�fJ,+y P��,.-���1 -/D 6� <br /> Inspection Form Included ���C'/, ��C.,� <br /> Comments Included: Dl - �7x' <br /> !�rBusiness Reps Signature Phone Number ecto s Si ure Phone Number <br /> INSTRUCTIONS ON BACK I Co Oct. corfect. ( A hw P L j 62081 <br /> White Copy: IW MB Yellow Copy:Operator Pink Copy:LEA <br />