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Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateClWM f181jNew , Survey Form - Page 1 l 5 - 4 2 5 $ 2 6 <br /> CIWMB 181 New 04!04 <br /> Callfornla Integrated Waste Management Board <br /> Part A- Survey BLUEOR BLACK INK PEN_ <br /> �Bu -Ines.Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t 3 2 O <br /> j® Routine Q 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 /> c4.W <br /> Physical Address w - b aw�, <br /> ou�l 05-- o C(-D, 3 ( ��aw �� 1 <br /> _s RI . <br /> �•y_ e' Inspection Date <br /> l `pp Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) — (Fill one only) I (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 U J 0 Active j # Passenger Generator <br /> Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude ® Hauler Q Indoor <br /> O Q inactive Truck <br /> Longitude _ Q Planned Q OTR O End-Use Q Container <br /> Business 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 ® Hauler Q Agriculture Q Shredder C) Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E FG C MENT$TATUi. ; <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ta " <br /> O O - .O Notice Of Vil6 /�;{ <br /> 0 ; Q PRC§42953 Contracts with Registered Waste Tire Haulers. compllance DaAd ne <br /> OjOj PRC§42956 Regi <br /> j - stration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements D6ta <br /> O O f 14 CCR§ 18458.1 (a)(b)(c)-Tire Program ID Number from C)WMS I II II L.�1� f' <br /> -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.2.1 (R69tIR�dfiv 1VO1/tir��� <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � r f :f • <br /> Q Q Other: § <br /> Comments � ��'i <br /> 1� t..awUy -_KV, �xwt.s �)_vo^vlj#tuK5 cv, t4P-0 A'S <br /> �`�-c5 ��'n.avti� ed Pfo`���.s5 � ��•-o�,��-Lvt...5� '�� ��Tt�I�L a��f-�551C.t�c-`+•���'4. <br /> Inspection Form Included: <br /> Comments Included: <br /> O Business Rep's Signature Phone Number Inspe for's Signature Phone Number <br /> INS t�����NS ON BACK Correct o Incorrect ( 1 e XI A MI P I L I EI z 2 13 62081 <br /> K" White Copy:CIWMB Yellow Copy:Operator Pink Copy:LFA <br />