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Waste Tire S <br />State of California <br />CIWMB 181 (New 04/04) <br />California Integrated Waste Management Board <br />PartA - Survey <br />Business Profile <br />TPID - <br />Site Suffix <br />Local <br />Identifier: <br />Business or Facility Name <br />Physical Address <br />Business Rep <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude – <br />Business Type (Fill all that apply) <br />4%y & Inspection Report• Inspection Report Number <br />Survey Form - Page 1 Il -1086986 <br />BLUE_ OR BLACK INK PEN <br />Inspection Details <br />s <br />v� <br />Inspection Type (Fill one) <br />Q Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />F,/ <br />Inspection Date <br />Q Auto Repair <br />Q Trucking Fleet <br />Q Government <br />Time In <br />Q Used Tire Dealer <br />Time Out <br />Q Car Dealer <br />Title <br />' <br />0 AM <br />0 PM <br />0 AM <br />0 PM <br />Q Hauler <br />Q Agriculture <br />J—J <br />Q Other <br />- -- Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />Q Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />O Q Closed <br />Q Altered <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />Q Truck <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q New Tire Dealer <br />Q Auto Repair <br />Q Trucking Fleet <br />Q Government <br />Q Retreader <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Collection <br />Q Crumb Rubber <br />Q Service Station <br />Q Hauler <br />Q Agriculture <br />Q Shredder <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2-1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Q <br />Other: § <br />Comments <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB--Enforcement <br />Q In Compliance - No Violatioris <br />Inspection Form Included: Q', -- / <br />n <br />Comments Included: OI <br />li Business Rep's Signature Phone Number Inspectors Signature Phone Number <br />INSTRUCTIONS ON BACK Correct* Incorrect: X " , \/ FE _x__[R m I p L, E 1 2 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />