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Waste Tire Survey & Inspection Report Inspection Report Number <br />irr Slat B181California Survey Form - Page 1 1 7- 1 0 1 3 5 4 3 <br />CIWMB 181 INew 04104) <br />California Integrated Waste Management Board <br />PartA-Survey_ BLUE_ OR BLACK INK PEN <br />Business Profile Inspection Details - <br />TPID _ <br />Site Suffix: <br />2 <br />I 3 3 �— - <br />D Inspection Type (Fill one) <br />® Routine Q Re -inspection <br />Q Referral Q Observation <br />Local� <br />Identifier: <br />7S;7 <br />If Referral, choose referral type (Fill one) <br />C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />_T` <br />Inspected By <br />— <br />Inspector <br />Physicaddtre <br />(Fill all that apply) <br />g — f d <br />0 Outdoor <br />Inspection Date O Cl / <br />Time In <br />Business Rep Title O AM <br />O PM <br />�l S t �fit�h 1��y Operational Status Tire Type <br />Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) <br />P If Active ® Passenger <br />- 0 <br />/ G / <br />o b <br />Time Out <br />Q AM <br />O PM <br />Business Role <br />Storage Type <br />(Fill all that apply) <br />(Fill all that apply) <br />® Generator <br />0 Outdoor <br />Latitude Q Closed Q Altered <br />GPS p Q Inactive Q Truck Q Hauler O Indoor <br />Longitude — Q Planned Q OTR Q End -Use Q Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part B Inspection of Waste Tire Dealer Generator Hauler and End -Use Facility )NFARCEMENT STAT (PS <br />(t1lftEfillENT;r .. <br />Q Q PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension,,:' <br />Q Q PRC § 42953 - Contracts with Registered Waste Tire Haulers. Compliarim Deadline <br />Q Q 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 ID 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 Q 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 Q 1 Other: § <br />Comments 1'1 <br />ction Form Included: <br />Comments Included: <br />INSTRUCTIONS ON BACK X(A pjL�� 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ■ <br />Li r 6,304. 0 o f <br />