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rer <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> StCalifornia Survey Form - Page 1 i 4 - 1 0 1 0 6 7 8 <br /> CWMB IWMB 181(New 04104) Y <br /> Cal7tomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details . I <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 8 5 Q ( O •Routine Q Re-inspection Q Referral Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> Identifier: TuxU�(� p( � C� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r< Tr'4_c�'? 3 - o S tease <br /> Physical Address <br /> Inspection Date b N / �L O O r <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> La k- keditarr, �1'cvd- <br /> -- ---- -- Operational Status The Type Business Role Storage Type <br /> Tire Count(WhoIeIPTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ° IS Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude O Hauler IS Indoor <br /> O Q Inactive ®Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair •Trucking Fleet O 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 Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q O PRC§42956-Registration/Decal in Vehicle . <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other: § .y /^ / <br /> Comments!�� J rtsi w_RE;, $ dAe- f hQ All @W?!'IO as-Nd.! �skActs <br /> 4ths �qXv'jc40 ( yKia ipor ►vea 6A Wiliam uJam �TtYe,EDT mmtz 2sfs v eoed- NV(' <br /> yio lafiens vl.a��. - <br /> Inspection Form Included:Q <br /> Comments Included:Q �� ��O �\ <br /> Bus ness Phone Number. sp tor's Si nature Phone Number <br /> INSTRUCTIONS ON BACK E X A'M P L E1 I <br /> z 62081 <br /> ■ E'17 L G E1'}.�1 b? White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA ® ■ <br />