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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> of <br /> CIWM 181jSurvey Form - Page 1 14 - 10065 1 <br /> CIWMa 181 New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLU$ OR BLACK INK PEN <br /> Business Profile _ - Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ! 9 �' S d j Q Routine Q Re-inspection Q Referral Q Observation <br /> Local _. , If Referral,choose referral type(Fill one) <br /> Identifier: A-.�yf� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or <br /> Facility Name ! Inspected By Inspector <br /> / <br /> Physical Address <br /> Inspection Date O [V Q 6 Q <br /> GA <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 PM 0 PM <br /> e.- <br /> Operational Status Tire Type Business Role j Storage Type <br /> The Count(Wh le/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply); <br /> Is Active Q Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered j <br /> GP$ Latitude Q inactive 0 Hauler Q Indoor <br /> D nacve Truck ruc <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill a�that apply) <br /> Q Now Tire Dealer Q Auto Repair Q 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 0 Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility gI FORGEM INT STATUS "__------ <br /> i <br /> "fit= `A;_ NAIlLINIItFEST-QEQUIREM,T <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q NotCns;Of lollatlon Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cbmwillilinbe'llsodlins <br /> Q Q PRC§42956-Registration/Decal in Vehicle m <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementste <br /> 0114 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days t` q f0rN0V or.EXT] <br /> Q Q 14 CCR§1$459.3-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 +ipl, etl S Snttretnent, <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O <br /> Other: § <br /> O <br /> Comments- - j,. t,.al a+-e- Oil, fr~ �lG2nnSa- 0� GR 5 T. c?9z,6:>— <br /> (' 5-7 '915 r. os- c;05 97)6 <br /> � r ss � l►�ss r s a ►-esl' � a CgAi, CI w <br /> -- M8 c 4vq �e, <br /> b'L+5ik1A65 gddnss —f-& �, ,^s1;-�5 /oc�,-('tom �e irs r�fia� o:� -7-1 <br /> Inspection Form Inch.ded: Q d <br /> Comments Incl ded: Q --- —- o � <br /> uslness R Signature Phone Number Irl!( is S gnat re Phone Number <br /> - j` 62081 <br /> INSTRUCTIONS ON BACK +* ;. J. E' AAS; �P,I 1 �T Cz, 3 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />