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.� Waste Tire Survey & Inspection Report -__ p_ Report _ <br /> � Ins Inspection Number . <br /> M <br /> State B 181(Nrnla Survey -Form - Page 1 - 12 - 1 006468 : <br /> CIWMB 181(New 04!04) - <br /> callfomlaIntegratedWasteManagement Board - <br /> Part A-'Surve BLUE OR BLACK INK PEN <br /> _ le -- - -.-.... .1nsPectinoDetaUs <br /> TPID i Inspection Type (Fill one) <br /> Site Suffix: - <br /> _-� Routine p Re-inspection Q Referral p Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier Q CHP Q CIWMB Q Complaint <br /> Q Hducational Visit-Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Pti _/cal'Address �p <br /> Inspection Date a / S / C) r- J <br /> yi „ g Time In - Time Out <br /> Business Rep Title — AM O AM <br /> � i <br /> I IO PMO O FM <br /> Operational Status T�Type Business Role `Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> r Active Passenger 40 Generator Q Outdoor . <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container. <br /> Business Type (Fill all that apply) — <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 •.�; a : ,� <br /> RVEN <br /> R151 M, <br /> :. <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires , - • <br /> Q 0, 'PRC§42953-Contracts with Registered Waste Tire Haulers. x <br /> Q Q PRC§42956-Registration/Decal in Vehicle - <br /> Q Q 14 CCR§1.8459 Responsible Entities Complying with Manifesting Requirements ` ° <br /> Q . 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q '14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs fora years s� >'.•s Y rc <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers A, <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q .0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y <br /> Q Q Other: <br /> Comments Nci.,✓ �� A `i�Zj._— <br /> !N10' <br /> Wa�sjL ow i •�ce 5 t- t1�\ <br /> 94 W <br /> �S e r <br /> Inspection Form Included: /�/'�/'�//J/�/�./� _ �1� <br /> Comments Included:Q Y ! /.%��/ � l71'1•�a'��,� _ - '? S3 70-8 <br /> Busmess:Rep's Signatfire .- Phone Number s 9 <br /> nature Phone Number. <br /> INSTRUCTIONS:ON BACKM <br /> 62081 <br /> Q � .4PLE 123 <br /> a� <br /> White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br /> 0525804.0169 <br />