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== Waste Tire Survey & Inspection Report Inspection Report Number <br /> State CIWM 181California Survey Form - Page 1 1 4 - 1 0 2 5 7 5 0 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> Business Profile +Inspection Details <br /> TPID- / Inspection Type (Fill one) <br /> Site Suffix. ` f Y ( U 4j Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> el <br /> `_ Inspected By Inspector <br /> Physlcalr4dress �(/� Y✓l 3 _ t� / �lrr-� / <br /> CIA Inspection Date 0 3 I Z / Z5 <br /> Time In Time Out <br /> Business R p Title O AM O AM <br /> 0P 0P <br /> Operational Status Tire Type Business Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that app)y)' (Fill all that apply)! (Fill all that apply). <br /> t 0 Active Q Passenger ®Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude II Q Hauler I Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude - Q 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 Q 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 ENFORCEMENT_8TATUS _ <br /> HAUI"�IINQ o 1 l��[10 vt RI±�GlElI�CEM�AI'CE <br /> O# O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O NQtIGIi;Of Vi0ltnlon O Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers, Cornpllilingo peadline <br /> Q O PRC§42956-RegistrationJDecal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB �._.J�-J I <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Rggkjked I t N{OV or EX7) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers I Q ReNiiid f C(WP--*Enforcoment <br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> OO 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O Q Other: § <br /> �!R`Y11oIptlOtas— <br /> Comments <br /> ��- � �n c.Tz•��Ka3 GLV s- r ���� Gvl.� �i%�i�- <br /> Inspection Form Included: Q ✓� 7�9�j <br /> a Comments Included: O Xusiness Rep's Signa Phone Num r spec i Phone Number <br /> INSTRUCTIONS ON BACK G'at t`t ` 1l tt � � E SC A m 6�r�, 1=2 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />