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Waste Tire ,Sur & Inspection Reportection Report Number <br />�6F � <br />Statlof California <br />':.. <br />.fo CIWMB 181(New Manage) Survey Form - Page -1 �. i 9 -.1 01, 3.3 3 0 <br />California integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - � � � J � � � - D � Inspection Type (Fill one) <br />Suffix: Site SC� .- Routine Re -inspection Referral <br />�' Q P Q Q Observation <br />Local - If Referral, choose referral type (Fill one) <br />Identifier: -'rte <br />•r J� y, -r7. - / Q CHP Q CIWMB Q Complaint . Q Educational Visit Q Other <br />Business or Facility Name Inspected B <br />P y Inspector <br />Physical Address Y I J - / 0 f <br />Street <br />L Inspection Date <br />Business Rep <br />Title <br />- t.n!fL _--e- I I <br />Tire Count (Whole/PTE)Q �'� <br />GPS Latitude I I I - <br />Longitude - <br />Business Type (Fill all that apply) <br />Q New Tire Dealer <br />Q Auto Repair <br />Q Trucking Fleet <br />Q Used Tire Dealer <br />Q Auto Body <br />Q Car Dealer <br />Q Service Station <br />Q Hauler <br />Q Agriculture <br />M <br />Time In <br />Tire Type <br />0 AM <br />Time Out . <br />m•m <br />(Fill one only) <br />0 AM <br />(Fill all that apply) <br />(Fill all that apply) <br />QPM <br />(5 Passenger <br />(g) Generator <br />OPM <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 />(5 Passenger <br />(g) Generator <br />Q: Outdoor <br />Q Closed <br />Q'. Altered <br />Q <br />Q <br />Q Inactive <br />Q. Truck <br />Q Hauler <br />Indoor <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Q Government <br />Q Collection <br />Q Shredder <br />Retreader <br />Q Crumb Rubber <br />Q Other <br />art B - Inspection of Waste Tire Dealer, Generator. Hauler and End -Use Facilitv <br />V <br />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 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <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 1 <br />Other: § <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m /m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />'✓ <br />■ <br />7 t` J���t.✓` <br />Inspection Form Included: Q' <br />r <br />Comments Included: Q) <br />Business Rep's Signature - Phone Number <br />Inspector's Signature <br />Phone Number <br />n <br />INSTRUCTIONS ON BACK Correct: Incorrect: ( ) <br />E .. f ' M P .LE 1112 3 <br />62081 <br />q■ <br />T <br />White Copy: CIWMB Yellow Copy: Operator <br />Pink Copy: LEA <br />® S <br />'i <br />'✓ <br />■ <br />