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s Waste Tire Sr6y & Inspection Repo Inspection Report Number <br />1iI�Z: State of California - - - - — Y <br />CIWM6181 (New 04104) Survey Form - Page 1 - <br />California Integrated Waste Management Board ._—._.__. <br />Part A - Survev BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />Duo <br />Inspector <br />" <br />r-� <br />I ! <br />HE <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />- <br />Inspection <br />Local <br />Identifier: i <br />Business or Facility Name <br />Physical Address <br />Street <br />City State ZIP Code <br />Business Rep Title <br />GPS Latitude <br />Longitude <br />Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair O Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler O Agriculture <br />O Govern <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 O CIWMB O Complaint Q Educational Visit Q Other <br />Inspected By <br />Inspector <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />Inspection <br />Date <br />O <br />O <br />Time In <br />0 A <br />Time Out <br />0 A <br />- <br />QPM <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />j 0 P <br />Operational Status Tire Type Business Role <br />(Fill one only) (Fill all that apply'; (Fill all that apply) <br />Storage Type <br />(Fill all that apply)'. <br />a Active <br />a Passenger <br />Q Generator <br />0 Outdoor <br />Q Closed <br />W <br />Q Altered <br />Q Hauler <br />0 Indoor <br />Q Inactive <br />O Truck <br />O Planned <br />O OTR <br />0 End -Use <br />Q Container' <br />ment O Retreader O Dismantler O Tire Derived Fuel <br />O Collection O Crumb Rubber <br />O Shredder O Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V ' A HAULING AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />O <br />O <br />Other: § <br />ENFORCEMENT STATUS <br />O Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />O Referred I CIWMB Enforcement <br />O In Compliance - No Violations <br />Comments <br />y( ') r + <br />i tt I I t t r f' L4 ., C . <br />t V 0 <br />Inspection Form Included: 0 <br />Comments Included Q <br />Business Rep°s Signature <br />Phone Number <br />Inspector's Signature v y <br />y, x,_Phane Numbe , <br />INSTRUCTIONS ON BACK Correct: <br />White Copy: CIWMB <br />Incorrect: X <br />Yellow Copy: Operator <br />A� i0YA1 L <br />i:,; . Y1 " <br />Pink Copy: LEA <br />62081 <br />