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=�e Waste Tire Survey & Inspection Report Inspection Report Number <br />State CWMB 81(Nrnla Survey Form -Page 1 # 2- 1 Q 6 3 3 <br />CIWMB 181 {New 04104} <br />California Integrated Waste Management Board <br />Part A - Survey _ ._ _ BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />ID • _ © Inspection Type (Fitt one) <br />Site Suffix: -7 0 Routine Q Re -inspection Q Referral ® Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: pggt. i`,-. „��y C77� O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or -Facility Name 1� <br />Inspected By Inspector <br />Phy ical Acildress `3 <br />Business Rep T� <br />r <br />Inspection Date O I C) <br />�52�5 Time In Time Out <br />Tire Count (Whole/PTE) t <br />GPS Latitude <br />Longitude — <br />Title <br />tO <br />O AM <br />O <br />0 AM <br />' <br />[QPM <br />O <br />0 P <br />O <br />Operational Status <br />TireType <br />Business Role <br />Storage Type <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />O <br />® Active <br />O <br />Passenger <br />® Generator <br />® Outdoor <br />� <br />O Closed <br />Q Altered <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 I 0 Other: § <br />Q Hauler <br />Q Indoor <br />D <br />O inactive <br />• Truck <br />i 0 Planned <br />Q OTR <br />O End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />O <br />tO <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />( <br />O <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 I 0 Other: § <br />Q Dismantler Q Tire Derived Fuel <br />Comments <br />(" ` (�-- �`Z o e' o • p h r` 15 -�5 <br />Inspection Form Included: Q <br />Comments Included: ')�'J�' & <br />_ — - - — —_ _ <br />Business Rep's Signa ure Phone Number In ctors S c <br />INSTRUCTIONS ON BACK [�; 'X rMt P <br />Whilo Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />