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Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWM of California Survey Form - Page 1 6 - 1 01 3 4 8 4 <br /> CIWMB 181(New 04/04) <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: 3 ..2— 9 Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �Q� �Q Fr.�H d0"-T_/'l� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> # /S�-� Inspected By Inspector <br /> Physical Address <br /> /e eda07" -"�&dA <br /> SY 1-2— Inspection Date O b <br /> Time In Time Out <br /> Business Rep Title / O AM / (l O AM <br /> PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) / 0 <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger i Generator 0 Outdoor <br /> O O Closed Q Altered <br /> GPS , Latitude Q Hauler Q Indoor <br /> O O Inactive Q Truck <br /> Longitude - O PlannedQ OTR O End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O 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 r <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> t <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 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 for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> rQ O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q 1 Other: § <br /> Comments <br /> y�i'ry /e,&.eetae N�,,,u a wz+t. C�i i tiro• cu Vr�w�..Q <br /> may, /ap c�e.0 f�i�rj ta��tfy/ al�bs� <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Business Rep's Signatu Phone Number Inspector's Signature Phone Number <br /> ■ INSTRUCTIONS ON BACK E X A M P L E 1 2 362081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> Nbi? <br />