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=s ; Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State o 181(New <br /> Survey Form - Page 1 I - 0 3 0 3 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey -_- _-_ BLUE OR BLACK INK_PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection- Q ` �Inspection Type (Fill one) <br /> Site Suffix: J / I ®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 /> Cwco,- ,I Wa ern , s 3 _ l J <br /> Physicall Address 9 J �Z <br /> ���s S• �Po�� V�Y <br /> C�- <br /> Inspection Date Time In Time Out <br /> Business Rep Title <br /> - /t O AM 0 AM <br /> L <br /> S " �°" fes" C .- O PM- 0 PM <br /> - - - -- - Operational StatusTire Type Business Role I Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ! (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' ' ®Active Q Passenger 1 ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ®Truck <br /> Longitude = Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ' <br /> 1' llIINGiiDF�IATIFET,REC,tJIREIVIENfS <br /> r <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tiresf, <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> Q 0 <br /> 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 ` K <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 y <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1_0 Other: § <br /> Commentstic <br /> j71U �� /►1.15 � _iv���_ �- f/�C '- '_ — <br /> 4 Wasfe r eclift w*r, 301 a Ike, <br /> �r o arc � <br /> IY2S_f cchCt Lcu�vl� fi� COYI'WaY4t o/tan is periiG(wA_ , �►�e,r - stern , Calti�tCt ,v1 Q ovt y <br /> xcd <br /> IT hf_(nobZkl os -th <br /> Inspection Form Included: <br /> Comments Included: S -- - <br /> Business Rep's Signature Phone Number Inspe is Si ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK011 <br /> A M P L E 1 12 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0627704. 0058 <br />