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Waste Tire Survey & Inspection Report inspection Report Number <br />State of California <br />CIWMB 181 (NewSurvey Form - Page 1 1 4- 1 0 0 0 3 3 8 <br />California Integrated Waste Management Board <br />Part A - Suryey — _ BLUE OR BLACK INK PEN <br />lBusiness Profile inspection Details <br />TPID -�j Inspection Type (Fill one) <br />Site Suffix: r 1j 7i _ ( Q Routine Re -inspection Q Referral Q Observation <br />Local C <br />Identifier: <br />Business or Facility Name <br />gqP f'jJrc� <br />Physical Address <br />4 4c7 o <br />Business Rop <br />Tire Count (Whole/PTE) <br />f <br />GPS Latitude <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 />3 C? - 1 0 ( <br />q9 <br />� <br />GrA <br />��i S <br />Inspection Date <br />O '7 <br />Time In <br />Time Out <br />Title <br />O AM <br />Q AM <br />0 P <br />0 P <br />Operational Status I <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 />' <br />1 S <br />e Active <br />® Passenger <br />Generator <br />0 Outdoor <br />C <br />Q Closed <br />Q Altered <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />® Truck <br />o <br />Longitude - Q Planned Q QTR Q End -Use Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Govemment 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 />I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />v ' �. �:►�t�t�,,,+�ii�.�.!ir��7' ���i�I�M�ntes � ; <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O O PRC § 42956 - Registration/Decal in Vehicle <br />Q Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Q 14 CCR § 18459.1 (a) (b) (c) - Tire Program (D 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 <br />Q O 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 1 Q Other: § <br />Q Dismantler Q Tire Derived Fuel <br />Comments C_ I Ji 1 (I- - 0 V/ r-1' <br />� Gr I I `► s r <br />l <br />i^GCa'_J f f -I- r P �a, r sc j 1 C;'5 1 <br />a Intim-- j 0 Cir rote— -hr-e-5 tom+Ue-- 1-J�. <br />Inspection Form Included: Q <br />Comments Included: Q <br />Business a 's igna <br />}i 4 <br />INSTRUCTIONS ON BACK <br />While Copy: CIWMB <br />Phone Number_ <br />Yellow Copy: Operator <br />Pink Copy: LEA <br />•e --Phone Number <br />3] 62081 <br />