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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> r tat 1811fornla <br /> SSurvey Form - Page 1 1 4 . 1 0 3 7 3 9 <br /> CIWMB 181(New 04/04) <br /> cslffomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile ilnspsction Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: 1_3 3 q (0 Q i® Q p Q Q Observation <br /> Routine Re-inspection Referral <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �9a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> /+(2C � �m� <br /> Physical Address Inspected By /y Inspector <br /> l,39 - 1 V <br /> aa U4 ►�: <br /> / "Law+e CA- (91 q5-3,36 <br /> Inspection Date 3 a 0 <br /> Time In Time Out <br /> Business Rep Title V ®AM Q AM <br /> �► <br /> )ier O W►fir O PM— 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r fit" (Fill one only) (Fill all that apply), (Fill all that apply) (Fill all that apply) <br /> •v 0 Active ®Passenger if Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill 211 that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader—ODismantler _0Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility i <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 1 Q PRC§42956-Registration/Decal in Vehicle <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 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 aoiva )VLSfecu ►-s tAP <br /> S af'( i4d • F"6ti <br /> des -fraulers fdr lranpr 6P ManRfa hor►les. l �xs are <br /> a how►e _._ �� �.Ices eF Wt 1and/ C'A"-r-ei DV" des <br /> rad"• Cas vim o vialslioxs <br /> Inspection Form Included:Q ^�2 <br /> Comments Included:Q <br /> Business Repla Vignature Phone Number r pector' gnature V Phone Number <br /> INSTRUCTIONS ON BACK E X A AkIPILIE1 11 2 3 62081 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA ■ <br /> 0615104.0571 <br />