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Waste Tire <br />Su &Ins ection Re Ort nspection Report Number <br />p p <br />% State of California <br />CIWMB 181 New 04/04 <br />t <br />Survey Form <br />- Page 1 1 <br />-- <br />� <br />- i o, 3 6 <br />California Integrated Waste Management Board <br />Part A Survey <br />---- --- <br />-------- --- ------ <br />BLUE OR BLACK INK PEN <br />�,. <br />� spection <br />TPID - <br />- <br />[V- <br />Inspection Type (Fill one) <br />Site Suffix: <br />0 Routine 0 Re -inspection <br />0 Referral 0 Observation <br />i <br />Local <br />Identifier: <br />Business or Facility Name <br />Physical Address <br />Street <br />If Referral, choose referral type (Fill one) <br />0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Inspected By Inspector <br />L, Lid - I I <br />Inspection Date /- <br />i=' ! <br />.fj <br />City State ZIP Code Time In Time Out <br />Business Rep Title 0 AM 0 AM <br />r m•��0PM 0 P <br />_j L_ <br />µ, Operational Status n ) Business Role <br />„- P k, r,w � <br />(Fill one only) ,(Fill all that apply) <br />I Active0 GeneratorL? L-)` <br />t�tt <br />O 0 Closed" <br />GPS Latitude m • n <br />r <br />o D Inactive <br />Longitude - FI—TI-11 0 Planned <br />0 New Tire Dealer <br />0 Auto Repair <br />0 Trucking Fleet <br />0 Government <br />0 Retreader <br />0 Used Tire Dealer <br />0 Auto Body <br />0 Car Dealer <br />0 Collection <br />0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING AND MANIFEST REQUIREMENTS <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 0 PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 0 PRC § 42956 - Registration/Decal in Vehicle <br />0 Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 0 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 0 14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 0 14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 0 14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 0 Other: <br />0 Hauler <br />0 End -Use <br />Dismantler 0 Tire Derived Fuel <br />j <br />;� a Y " °'rf� ", *`r M ✓i <br />InS `ector•S Si natUrM?a'M�il ,"�r/ rqM� k5%M;' o'II"�#"� a ,�"• <br />p's Signature - Phone Number p <br />_ ... 62081 <br />INSTRUCTIONS ON BACK Correct: 10 Incorrect: X �/ i; v A.Mj P 611 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />