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Waste u�� Tire Survey & Inspection ReportInspection Report-Number <br /> Integrated <br /> Waste <br /> M Survey Forme- Page 1 t 7 - 1 01 .4 81. 4 7 <br /> CIWMB 181(New 04104) <br /> �Californla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection© ' Inspection Type (Fill one) <br /> ffi . - <br /> Site Suffix: S ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localr � If Referral,choose referral type(Fill one).: <br /> Identifier: S01_,)%a�Nl.«h.. W tNW 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name d <br /> inspected By Inspector <br /> Alt. ,,-T r p Y"-,r� ` <br /> Physical Address ` 7' - \ (> G�vV� c-,,- <br /> C_C' <br /> •,,-C.a <br /> 0 J-1-C U V\ f�C QI 7�t L Inspection Date <br /> `f a t Time In Time Outt <br /> Business Rep Title \\ / O AM O AM <br /> �vW t c v v I2 EI O Z > 5- Q PM (7 A PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE). t --� 0 (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ; (0 Active 0 Passenger ®Generator ®Outdoor <br /> Latitude O 1 0 Closed 0 Altered <br /> GPS 0 Hauler ®Indoor <br /> O 0 Inactive Q Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply). <br /> 0 New Tire Dealer 0 Auto Repair 0.Trucking Fleet 0Government 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 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ` I „ <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 /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> ys ?i <br /> 0 0 14 CCR§18459 ,Responsible Entities Complying With Manifesting Requirements x= <br /> 0. 0 14 CCR§18459.1(a)(b)(c)-The 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 /> � ' r <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 Facilities � t.�t,z�• <br /> 0 0 14 CCR'§18462-Manifest System Requirements forTire Dealers or Waste Tire Generators' <br /> 00 <br /> Other: § ^�^ <br /> Comments t( `'� � � '� '��.,_ �. •,' . ag <br /> �t5 ra.Lll��n",t $ \AL \ � �AA.AZ Iff-15 MS;k!A. 44n( <br /> l [�tto <br /> w40 �I OVA��'I�h..eNom�h., <br /> Inspection Form Included:0Comments Included:0. sines Reps Signature I of signature; Phone Number <br /> r(� f 82081 <br /> INSTRUCTIONS ON BACK <br /> �. °8 � r E M d4 iflll Pi23�. <br /> ■ Whfte Copy:CIWMB Yellow Copy.Operator Pink Copy:LFA ® ■ <br /> 0529204.0839 <br />