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` Waste Tire Survey & Inspection Report p p <br /> °IIie� Inspection Report Number <br /> r State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 - 1 0 1 0 60 5 <br /> California Integrated Waste Management Board <br /> PartA-Survey _ _ BLUE_ OR BLACK INK PEN <br /> Business_P_rofile Inspection Details <br /> Tite - / / © Inspection Type (Fill one) <br /> Site Suffix: •Routine Q Re-inspection Q Referral Q Observation <br /> LocalH�'w Referral,choose referral type(Fill one) <br /> Identifier: Sfr{�f l JQ(�g N Q CHP Q CIWMB Q Complaint Q Educations!Visit Q Other <br /> Business or Facility Name v (]`f� "' — — <br /> / esa, &o (dm <br /> �e / CInspected By uh <br /> ` ! Insp�ec^tor <br /> r l , <br /> Physical Address f/ ✓µ' 3 9 — / O l <br /> l 8 sof W, Sty f�xd kd - yt� V <br /> 95 l[, � Inspection Date V Oq <br /> Time In Time Out <br /> Business Rep 11 Title <br /> 0 AM O AM <br /> L am G f7 C> --— O PM — — ..._ O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �. t / }rt (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> (f 40.Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor <br /> O Q Inactive Q 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 Q Trucking Fleet Q Government Q Retreader O 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 ®Other �wit, r�(p(CiI L�l <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ' s <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires a <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. M�' <br /> O O PRC§42956-Registratlon/Decal in Vehiclek <br /> O O 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements 4 <br /> O O 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> c <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs Within 90 days . <br /> O O 14 CCR§1 B459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> u : � <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generatorsy . <br /> O 1 O 1 Other: § - ° <br /> CommentsRvzo, l� <br /> h acmowxg OfRu,. At WuAble ristA, -Kra &Lft <br /> Mid io 10 S,law Y N bI dCMLS0fd <br /> Inspection For Included: - <br /> Comments Included: <br /> Business Rep's Signature Phone Number lnkjaAes Sigbofure Phone Number <br /> - � <br /> INSTRUCTIONS ON BACK ' y b X AIs P .t :Z 3 62081 <br /> cc s ' ass <br /> ■ White Copy:CIWMB Yellow Copy:Operator <br /> Pink Copy:LEA ■ <br />