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Waste Tire Su*ey & Inspection Repo Inspection Report Number <br /> State CIWM 181(New Survey Form - Page 1 1 2 - 1 01 4 9 0 0 <br /> CIWMB 181(New 0410A} <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � -2, <br /> � -7 � � - � � i Inspection Type (Fill one) <br /> Site Suffix: � (Q Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Address 1 © fv '%r✓7G�-'C"�S <br /> L <br /> �� Inspection Data © � � 0�� I C> S" <br /> rr'� Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> O PM 0 PM <br /> 4 e" `� Operational StatusTire Type Business Role I Storage Type <br /> ^ <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply); <br /> 'ry <br /> ®Active tt Passenger I& Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR i Q End-Use Q Container <br /> Buslness Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 ®Other �� � �!L / i✓` <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENI OR'#M STAT <br /> V A` HAULING AND MANIFEST REQUIREMENTS Q Natico Of V1011etlgnQ Fyzf�b�y�#�r�i <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> Q Q 1 PRC§42953-Contracts with Registered Waste Tire Haulers. C6rflplls9 D68dIM# <br /> O Q PRC§42956-Registration/Decal in Vehicle m j <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 114 CCR§ p �9 Y 18459.2.1 -Submittal of Manifest Forms and Tire Tri Logs within 90 days lR�q � rar y t��✓i <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 � d� � <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 /> *01, <br /> Other: <br /> , Y l <br /> �- �' <br /> Q Q Other: - <br /> Comments <br /> app�v <br /> iInspection Form Included: QI <br /> Comments Included: Q' - - - - <br /> Business Rep's Sfsnature Phone Number Insp o Si atu Phone Number <br /> INSTRUCTIONS ON BACK corl Inc:raITtl : { E ? AMP 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />