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Waste Tire Survey & Inspection Report Inspection Report Number <br />StateCWMO181(ornla Survey Form - Page 1 13 -1 0 $ 4 Z <br />CIWMB 761 (New nag4) Y ry <br />California Integrated Waste Management Board y <br />art A - Survey BLUE OR BLACK INK PEN <br />usiness Profile Inspectlon Detalls <br />-PID -l/ ' 1 - ©� Inspection Type {Fill one} <br />>ite Suffix: I / (-J 1i 0 Routine Q Re -inspection Q Referral <br />-ocal <br />dentifier: <br />lusiness or Facility Name �'" <br />FZ ` +rE: <br />hys cal Address <br />1lvdi <br />Isiness Rep Title <br />Tire Count (Whole/PTE) <br />0 <br />13 PS Latitude <br />0 <br />Longitude - <br />Business Type (Fill all that apply) <br />fi Q New Tire Dealer Q Auto Repair <br />Used Tire Dealer Q Auto Body <br />Q Service Station Q Hauler <br />Q Observation <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 />Inspection Date D / <br />Time In Time Out <br />0 AM <br />O PM <br />Operational Status Tire Type <br />Business Role <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />Active <br />Passenger <br />® Generator <br />Q Closed <br />i <br />Q Altered <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q Hauler <br />Q inactive <br />Q Truck <br />Q <br />Q Planned <br />Q OTR <br />Q Fnd-Use <br />Q Trucking Fleet Q Government Q Retreader <br />Q Car Dealer Q Collection Q Crumb Rubber <br />Q Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />I HAOLING 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 />O <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 />Q <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 <br />Other: § <br />O AM <br />Q PM <br />Storage Type <br />(Fill all that apply); <br />Outdoor <br />Q Indoor <br />Q Container <br />Q Dismantler Q Tire Derived Fuel <br />Comments'a oil /* u �j�-5 A)1— rI+'�Pc�� ! r l�'e. JW �'`'f� � Cts rG�ct!(5t--�u' t..%i <br />- ;r -e- ha vila-- 4e> ct,- 0646.--f-►'+".�S �r. / 141 <br />�,✓a� Urns,' �q � �3"� �". L�iS <br />no%�" <br />Inspection Form Included: <br />Comments Included: -- <br />Business Rep's Signure Phone Number actor s Signature Phone Number <br />INSTRUCTIONS ON BACK Ca _ Mc�teatr �_ E �t I R�r 62081 <br />White Copy. CIW Yellow Copy: Operator Pink Copy: LEA <br />