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Waste Tire Survey & Inspection Report <br />State of Callfornla <br />CIWMB 181 (ewoMo4) Survey Form - Page 1 <br />California Integrated Waste Management Board <br />'art A - Survey <br />Inspection Report Number ■ <br />1 1.1010741 <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />TPID -I nr 1 <br />Site Suffix: jS Ot <br />Inspection Type (Fill one) <br />Q <br />PRC § 42956 - RegistrationlDecal in Vehicle <br />0 <br />(9 Routine Q Re <br />-inspection <br />Q Referral <br />Q Observation <br />Local C� 1 <br />Identifier. J C <br />If Referral, choose referral type (Fill one) <br />O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />��"" �� <br />StD(- Vvhu-( ViG�- <br />Inspected By <br />O <br />Inspector <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Physical Address <br />- <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />1��n�, <br />O <br />14 CCR § 16461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />V <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Inspection Date <br />1 Other: § <br />-�j <br />comments 'ihLpenSm l /��t- Co <br />l .. n � <br />%-qk! <br />! <br />f �.1 � _ r e!' ! /wf � n... � 1 e .Y�IY•LV I . i!'E'!` �.r i I Vi!'.TA •TfiI�O <br />Time In <br />Time Out <br />Business Rep Title <br />O AM <br />O AM <br />0 PM <br />0 PM <br />- - <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type . <br />Tire Count (Whole/PTE) 1 O <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply <br />® Active <br />® Passenger <br />® Generator <br /># Outdoor <br />Q Closed <br />Q Altered <br />GPS Latitude <br />Q Hauler <br />Q Indoor <br />O <br />Q Inactive <br />®Truck <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection <br />Q Service Station Q Hauler 0 Agriculture Q Shredder <br />Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Crumb Rubber �� �p1,tM0G'f �r, �t %� 1� <br />® Other V� & Oma' vlice '> ! jhj*,,t <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />Q <br />PRC § 42956 - RegistrationlDecal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />Q <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 16461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />1 0 <br />1 Other: § <br />-�j <br />comments 'ihLpenSm l /��t- Co <br />l .. n � <br />%-qk! <br />! <br />f �.1 � _ r e!' ! /wf � n... � 1 e .Y�IY•LV I . i!'E'!` �.r i I Vi!'.TA •TfiI�O <br />Jct,6�13 � R uXienS <br />Inspection Form Included: Q <br />Comments Included: Q - <br />Business Rep's Signal <br />INSTRUCTIONS ON BACK <br />■ 0716`04.01 16 White Copy: CIWMB <br />Ill <br />la ; S A&ed n ) lu`S _ <br />rLoa-5Ct a Edi•]- NdCct <br />n i_ " 0 _ t_ r« I! Is --4-- 1 -L 1 <br />Phone Numberns toes I ature Phone Number . <br />OX-1OX-1 A IMI P L f 1 3 62081 <br />Yellow Copy: Operator Pink Copy. LEA ® ■ <br />