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spection Report Number <br />® _ Waste Tire Sur y &Inspection Report n_ <br />B 181 (ew 04104) <br />California Integrated fornia <br />CIWaState of lste Management Board Survey Form - Page 1 -1 0-,_ .105 5 -4_ <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile 4 <br />/ <br />Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />Time In <br />TPID - <br />Site Suffix: / r ( <br />r• <br />f �.) <br />A <br />Local <br />Identifier: <br />�^ <br />0 AM <br />LEI <br />0 PM <br />m ' <br />0 PM <br />Business or Facility Name <br />Business Role <br />Storage Type <br />(Fill one only) <br />(fill's rry��� <br />(Fill all that apply) <br />(Fill all that apply). <br />Active <br />0 P S ii e <br />0 Generator <br />0 Outdoor <br />0 Closed <br />Physical Address((`` <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />0 Hauler <br />w' <br />0 inactive <br />l ._% k.• <br />1J L 1 : <br />Y l jl <br />0 Planned <br />Street <br />0 End -Use <br />0 Container <br />-fit; �' <br />l <br />City <br />State ZIP Code <br />Business Rep <br />Title <br />X <br />GPS Latitude I I I. <br />O <br />Longitude – <br />Business Type (s=ill all that apply) <br />Inspection Type (Fill one) <br />(DRoutine 0 Re -inspection 0 Referral 0 Observation <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By <br />L Id —d <br />Inspector <br />Inspection Date HI/ <br />/ <br />Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />Time In <br />Station 0 Hauler 0 Agriculture 0 Shredder a Other <br />Time Out <br />V <br />A <br />0 AM <br />�^ <br />0 AM <br />LEI <br />0 PM <br />m ' <br />0 PM <br />Operational Status rr <br />Business Role <br />Storage Type <br />(Fill one only) <br />(fill's rry��� <br />(Fill all that apply) <br />(Fill all that apply). <br />Active <br />0 P S ii e <br />0 Generator <br />0 Outdoor <br />0 Closed <br />0A) r", ,p <br />"�' <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />0 Hauler <br />0 Indoor <br />0 inactive <br />O Truck y I yf <br />00 <br />0 Planned <br />0 QTR <br />0 End -Use <br />0 Container <br />0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader <br />0 Used <br />Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service <br />Station 0 Hauler 0 Agriculture 0 Shredder a Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />00 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments 1 <br />i l t. t •L l _' ( r 4^ t l t t l .1(t V. <br />3�\ <br />0 Dismantler 0 Tire Derived Fuel <br />t <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date <br />O/m/m <br />(Required for NOV or EXT) <br />0 Referred/ CIWMB Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: 0; <br />Comments Included: 0 <br />Business Rep's Signature Phone Number/ Inspector's Signature <br />INSTRUCTIONS ON BACK Correct: ® Incorrect: �0 `;; P� M c (.„; i r . a <br />■_ .. <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />i <br />Phone Number <br />62081 <br />® ■ <br />