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Waste Tire Su & Inspection Re or*_Inspection Report Number <br />u:. Y p p <br />Gri3� State of California <br />®663'ZQ CIWM6181(New04/04) Survey Form - gage 1 i 3 1 u 1 3 4 8 1 <br />California Integrated Waste Management Board --- - - --- -.--- <br />Part <br />��A;ry- Surve BLUE OR BLACK INK PEN <br />�'ti�S.;t ..r ry ,"ori J✓ n rNdP #"'�iv� t��s i,la <br />t �.,, r ✓ ��,�,a„t , �w. We ti. nretstiArr Details <br />TPID - <br />Site Suffix <br />l 17” <br />Local <br />Identifier: ' r rq r <br />Inspection Type (Fill one) <br />Routine Q Re -inspection O Referral O Observation <br />If Referral, choose referral type (Fill one) <br />O CHP Q CIWMB O Complaint O Educational Visit O Other <br />Business or Facility Name <br />- _ Inspected By <br />Inspector <br />r <br />_.._ - <br />Ph slcal Address__ <br />— 1 l <br />< <br />Street '-- <br />Inspection <br />Date <br />t� <br />City <br />Business Rep Title <br />State ZIP Code Time/. In <br />.r <br />Q AM <br />Time Out <br />J 0 AM <br />O PM <br />PM <br />Operational Status <br />r ` (Fill one only) <br />�� �� <br />Business Role <br />(Fill all that apply) P'pFT{ <br />r� <br />® Active <br />M✓"�,/�^�*rhrV ✓i✓ehd�b"�4�1Y���.. <br />Yd <br />tIa�,: <br />"�µFYSr✓bV r�,�`✓gd AY/� b .. <br />N fl M�'nC' 'lprd <br />®GeneratorItltt? I{ <br />`ta <br />GPS Latitude O O Closed <br />O O Inactive <br />Longitude — . T1 Q Planned <br />O New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader <br />O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber <br />O Service Station Q Hauler O Agriculture Q Shredder Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />O O PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O O PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O Q PRC § 42956 - Registration/Decal in Vehicle <br />O 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />O Q 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q O 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 O 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 O 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 O 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O Other: § <br />Comments <br />0 Hauler <br />Q End -Use <br />Dismantler O Tire Derived Fuel <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X'7" 1 - r��o�0i�� Y� µ C V z i 2 � � 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ■ <br />hi <br />