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�i Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stertor <br /> 181(New 04104) <br /> CIWMB 181(New Survey Form - Page 1 1 6 - 1 0 1 0 7 1 3 <br /> CalHomia Integrated Waste Management Board <br /> Part A_-Survey BLUE OR BLACK INK PEN <br /> BusinesatProAle inspection Detalls - <br /> TPIp. ' a `751 ,� - 0 Inspection Type (Fill one) <br /> Site Suffix: O) ®Routine O Re-inspection O Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Uj Business or FaCCCcili """'���tyN"`���me <br /> a �L <br /> 1 C � Inspacad By Inspector <br /> J Tffc <br /> Physical Address 39 1 a <br /> Inspection Date Q� &` � V <br /> h Wl�V(C f IWOh ✓�((f'/ Time In V Time Out (( <br /> Business Rep ''//,,, Title O AM O AM <br /> 1eN1•h • O PM QPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r ` V ®Active (9 Passenger ®Generator ®Outdoor <br /> GPS Latitude O Q Closed Q Altered Q Hauler <br /> Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q End Use Q Container <br /> Q Planned Q OTR <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 <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 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 Fortes and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q . 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other. § <br /> Comments <br /> v <br /> -F S ds Wa l dac, eSt S <br /> h <br /> L ,, � ri D <br /> Inspection Form Included:Q - <br /> Comments Included:Q <br /> B pees ep's Signature Phone Number" In oi's_gn are. Phone Number <br /> INSTRUCTIONS ON BACK A p E 3 62081 <br /> ■ 0716504.��4� White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />