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a"'-' Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 19 - 1010 60 9 <br /> Californla Integrated Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile _ _ - - _ Inspection Details — -- - - -- <br /> TPID- O O ^ - Inspection Type (Fill one) <br /> Site Suffix:. "� <br /> ®Routine Q Re-inspection <br /> Local0 Referral 0 Observation <br /> � If Referral,choose referral type(Fill one) <br /> Identifier: --�C �',w l �oQl,1 C�(,{ Q CHP Q CIWMB Q Com laint <br /> p Q Educational Visit Q Other <br /> Business or Facility Name <br /> O� Inspected By Inspector <br /> Physical Addr s j J G� - t a <br /> 5a0 Tr-(LCy 8V-v-�/-U - - <br /> I-v-�G((,,// ^ �( /; 1� Inspection Date <br /> I / •f`f- �l7JC l/ <br /> / Time Out <br /> Business <br /> ``Rep <br /> nn� �t Title Time Q AM 0 AM <br /> (�►4- �2SoC�Sa� �r /"` I O PM O PM <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) F apply) (Fill all that apply) <br /> Tire Count Whole/PTE r r 3 D pp v) ( ill allthata I <br /> ®Active 0 Passenger 0 Generator ®Outdoor <br /> GPS Latitude <br /> Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> OLo�plr:- <br /> ctive Q Truck <br /> Longitude - nned Q OTR Q End-Use Q Container <br /> Business Type (FIJI all that apply) <br /> — L i <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 J <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. ;z <br /> Q 1 Q PRC§42956-Registration/Decal in Vehicle <br /> QQ 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 x• . „� � <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 /> g�R^ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q 1 Other: <br /> Comments <br /> o_- ��e ti o i o <br /> Inspection Form Included:Q' <br /> Comments Included:Cy <br /> B nese Rep's Signature Phone Number I e or's ig tura _ Phone Number <br /> ■ INSTRUCTIONS ON BACK ^ �qy p .2 62081 - <br /> ® ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0711604.0135 <br />