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« , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State B181(Ne la Survey Form - Page 1 I - 1 41 3 79 7 <br /> CIWMB 181(New 04104) <br /> CalHomie Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- /} fO Inspection Type (Fill one) <br /> Site Suffix: I 0 -7 1 / g ! I ®Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local �{` If Referral,choose referral type(Fill one) <br /> Identifier: �.JI �,( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name !��J <br /> �e,ti,wr Ta A � 09� Inspected By J'� / Inspector �(/1/,' <br /> Physical Address 1 c//„ `�Il) 3 - C ✓ ` ��(/�( '�Wl Z <br /> /�/I Ar / Inspection Date O 7 I 0 ,3 Q <br /> v/J (O Time In Time Out <br /> Business/Rep Title O AM 0 AM <br /> A/�f IlaA* O PM - O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) /1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator 9 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 *Container <br /> Business Type (Fill all that apply) <br /> IR New Tire Dealer !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 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 Entitles Complying with Manifesting Requirements <br /> iQ 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 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 Other: § <br /> Comments pn -� 7/ h)' LO r/l4SL( <br /> uses >4(berfds ljgg T(YeS (TP&14a539S-oj) `s of uSdR_` uxt�e <br /> 1'�S• ► Was /aa 0.TL 0,0 KJed e A U AS C1P1QrOX I x nfir Modk 4 <br /> No \f►DLafbrLS• <br /> Inspection Form Included:Q 9�1/� <br /> Comments Included:Q ✓� 1� <br /> Business ReAp's Signatu a Phone Number In�ector's Ig ature Phone Number <br /> INSTRUCTIONS ON BACK IEIxIAIAkIP LIE[ (11213( 62081 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br /> 0622104.0015 <br />