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° = Waste Tirej Inspection Report Number <br /> State California Y <br /> CIWMBB 181(New 04/04) r <br /> California Integrated Waste Management Board ourvey <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: \ t Routine Q Re-inspection Q Referral Q Observation j <br /> Local .If Referral,choose referral type(Fill one) <br /> Identifier: �� 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ---- -- --- __ <br /> Inspected By Inspector <br /> OVIA <br /> Physi I Address o <br /> , <br /> - <br /> ® Inspection Date � <br /> V rvZ e 1 5 3b0 <br /> Time In Time Out <br /> Business Rep Title O AM Q AM <br /> PM Q PM <br /> -- -- <br /> -- 'Operational Status Tire Type Business Role � Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> s Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS <br /> Latitude ° Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) 1 <br /> Q New 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection ofWaste Tire Dealer, Generator, Hauler and End-Use Facility <br /> Q O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Qi } 1 i tiler h °rx� <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> a <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements r �} � <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 <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers w <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 /> Q Q Other: § <br /> Comments <br /> Ap <br /> - - <br /> AI�Aov V5 0k_VI <br /> _ g t gam. <br /> !Inspection Form Included: Q r— <br /> Comments Included: Q --- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />