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Waste Tire Survey & Inspection Report Inspection Report Number <br /> ClIM 181(California Survey Form - Page 'I 1 9 0 4 8 3 2 <br /> CIWMB 181(New 04104) r <br /> California Integrated Waste Management Board <br /> Part A-Survey __ _ _- _ BLU_ E OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- ' U _ Inspection Type (Fill one) <br /> Site Suffix: , l 3 ` ® 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 <br /> Inspected By Inspector <br /> Phsical Address - , p <br /> 20� <br /> / l Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> QPM QPM <br /> -- - - --- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill ail that apply) (Fill all that apply) <br /> Q Active ® Passenger ® Generator ® Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS 1 Q Hauler Q indoor <br /> o Q Inactive Q Truck <br /> Longitude = Q Planned Q OTR O End Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> '�` .>b,5 �'`/.,8.��i iv'�:r �[•-1�'`1Y�c,��f�j�1�.� �+�sy�" ({trF�y'�.p -: , '�jr li1'f r r . ,-i y/rr _ 7 //r rl�it���f��� �%J f/moi <br /> :�i-'y. . „�,i•y'�'7 �r�lAi"+I�r�'�il``.�1�Fwi'ryi�.�l�1FrE'1:117f -. . .,..,,<•rr/..%c.fih. .i..d/ .rri;yt:/• r�/{/ � ��/y „r, i iii �j <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> O O <br /> PRC§42956-Registration/Decal in Vehicle <br /> O 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 /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Lo s for 3 ears �' / <br /> O ' O § eg 9 Y `� ' /,•jj/�ar���,:'.i//, ,///.✓fes a <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q O :14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities r ' <br /> r <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § <br /> Comments _ u 5`� �4-t, U <br /> -15t t�5 <br /> 1.C�� a "XA <br /> (��+5 <br /> � 0 <br /> �►��.� os-��>\_ � -s �l� �� _ zoo `���-S �-�..- - <br /> Inspection Form Included: O o� <br /> Comments Included:O — - — ��- <br /> _i Bush s ep's Si nature Phone Number Inspec or's Signature _ Phone Number <br /> trdf&w'�i' �-' �T.�/i "'6 �'' 62081 <br /> INSTRUCTIONS ON BACK � v �y IeX i� M p L E Z 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />