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`°'■ a.: Waste Tire Survey & Inspection deport Inspection R Number <br /> � . . <br /> State of California <br /> ' - t <br /> CIWn <br /> MB 181(New 04104) 16 10a $ 447 '€ <br /> caliremis Integrated Waste Maagement Board SurveyForm - Page1 <br /> ...,_ r <br /> Part A-Survey_ BLUE OR BLACK INK PEN <br /> Profile 4'- oaDefalls. <br /> TPID _r I _ pp .-1 -- Inspection Type(Fill one)— -- '- <br /> Site Suffix l .p � o—i •Routine Q Re-inspection Q Referral Q Observation <br /> Identifier: i $Referral,choose referral type(Fill one <br /> ) <br /> QCHP QCIWMB QCom faint <br /> 0 Educsoral visit Q otherLocal <br /> Business or Facility Name-- ----- inspected By Inspector <br /> Physical Address ____ <br /> ( T <br /> 5:reoi —_•-—— � Inspsetlon Dab dr I <br /> Time In Time Out <br /> Business Rep Title - >�AM } i I_ O AM <br /> � <br /> O v I <br /> 0 P OPM <br /> C.�t•-� ��t •�. ?NWIvaDvwv <br /> - 'Operational Status j Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill:altthatapply) (Fill all that apply) (Fill all that apply) <br /> t �� ®Active •Passenger' Generator •Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q indoor <br /> 0 Q Inactive Q Trude <br /> Longitude - Q Planned Q 0* ` Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0Trucking Fleet Q Government Q Refreader 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 EDd-Use Facility <br /> O 0 PRC§42951-Waste Tire HaulerRegistra8on and Transport of Tres <br /> 0 10 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCk§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 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 Longs for 3 years <br /> Q 10 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 0-.1.4 CCR§18482-Mandeat System Requirements for Tire Dealers or Waste Tire Generators <br /> Comments. <br /> Inspection Form Included,0 �j_2 7`s - <br /> Comments Included:p Rib- ZS-'l' / 5J 1 D/ <br /> Business s.S nature ,.Phone Nuiibac> ; n Phone Number <br /> INSTRUCTIONS ON BACK PILIE113 62081 - <br /> ■ - A �1 f1!•S A !•]] White Copy CIWMB Yellow Copy.Operator Pink Copy.IFA --� •�• <br /> 0525004.0153 <br />