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00 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> SW. <br /> tWCaligeM Survey Form - Page 1 1 0 1 0 1 3 7 4 0 <br /> CIWMB 181(New 04/04) <br /> CalHomla IntegnlW Wage Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Dstalis <br /> TPID- ! - / Inspection Type (Fill one) <br /> Site Suffix: ( b v 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local l 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 - <br /> � O -a re S Inspected�BY Inspector <br /> ` Physical Jess �t - I 0 / <br /> 310 G Yoe. .0 Vd <br /> ,Vl <br /> A / U"1 l04 �3,3/U„ Inspection Date D 2 / ) o I NO <br /> ✓ w <br /> Time In Time Out <br /> Business Rep Title <br /> �f� y,,, C o �AM I � O AM <br /> S� i CN� (;1�,1�l S'L'•c•�1.1L I � � O O PM l � A PM <br /> — Operational Status Tire Type Business Role i Storage Type <br /> Tire Count(Whole/PTE) t �1 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> V ®Active ®Passenger &Generator a Outdoor <br /> Latkude O Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Cortyltude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Businm Type (Fill all that appy) - <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retrsader Q Dismantler O Tire Derived Fuel <br /> 46 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture O Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 O 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 /> O 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 Q Other: § <br /> Comments L� - WOW; 'AlaS h p h-d s m <br /> has c c,5ec@�L�as e es removed t,a ,n ��e. "lw i Vies! fbv- <br /> F�& Of Oil c e�A('�' k- a�m�5cirnu y AD fires oLfa Itme. Used, fig' <br /> w ad¢=ansa �V Viotafzis. <br /> Inspection Form Includd-ee- Signature <br /> Q <br /> �W+17966Comments ncluBusiness RPs S nature Phone Number tun Phone Number <br /> ors <br /> INSTRUCTIONS ON BACK +i E X A AA P L E[ 1112131 62081 <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA ® ■ <br /> 0615104.0573 <br />