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«r, Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> stataefCallfornla Survey Form - Page 1 I . 0 3 3 3 5 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- I L Inspection Type (FUI one) <br /> Site Suffix: 4 0 q $ �- g - Q Routine Q Re-inspection Q Referral 6 Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name r <br /> � Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Business Rep �$L -Z_��q Title Time In 0 AM Time Out AM <br /> c Z �l •PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' t 0 ®Active Q Passenger. ®Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q 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 p Auto Repair •Trucking Fleet p Government p 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 /> owl <br /> - .3e� ti T 19✓P+X`'�K mak: <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 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 Y <br /> r <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 /> .,. ' <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § /I <br /> Comments SI�^GS ' LtSr-t.Sr�f G 1 'L� 1 i%5 i eo��VGS <br /> ��•�ia-..- -�-1S C 1�1�1 does K.+- <br /> hv+- wwr_ <br /> Inspection Form Included:0,- <br /> -Comments Included:Q` � �g_�!I <br /> Business Rep's.Signature Phone Number In ctor's Signature Phone Number <br /> INSTRUCTIONS ON BACKso LEr A F 62081 <br /> ■ White Copy;CIWMB Yellow Copy:Operator Pink Copy.LEA © ■ <br /> l_1 C.P15_F14,0529 <br />