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«�= Waste Tire Survey & Inspection Report Inspection Report Number <br /> rr <br /> State ot California Survey Form - Page 1 ( 5 - 1 0 1 0 71 z <br /> CIWMB 181(New 04!04) <br /> cwwomla Integrated Waste Management Board <br /> Part A-Su rve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Detalls <br /> TPID- O - ! Inspection Type (Fill one) <br /> Site suffix: / I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> l entlfl If Referral,choose referral type(Fill one) <br /> Identifier: !t� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name inspected By Inspector <br /> Physical Address-IfQ 3 -1 0 ( 'j/I,k p, ,-RQ� <br /> W-`�� 1 - <br /> �.�QI� Inspection Date <br /> Time In Time Out! <br /> Business Rep Title 0 AM 0 AM <br /> �'�eJ2 Erne. �n/��S � 0 PM QPM <br /> w v'l Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (FIR all that apply) <br /> r ID Active •Passenger .Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> G17S Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires II <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 1 0 Other. § <br /> CommentsRnlctm <br /> Ivo • . jZ �- <br /> ` 12VQ Tug otc'.snoSa,P 7' urx ��J <br /> J� K-6 .0-d - - - <br /> Inspection Form Included: <br /> Comments Included: <br /> aturw Phone Number'. I sp or"s' n re:: Phone Num_b_er <br /> INSTRUCTIONS ON BACK FIR irAJAII[IP RLTE I 11 2 62081 <br /> ■ 0716504.0058 White Copy.CIWMB Yellow Copy.Operator Pink Copy:LFA ® ■ <br />