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57iSWaste Tire SuW & Inspection Reportnspection Report Number <br />State of California <br />CIWM6181(New 04/04) Survey Form - Page 1 I- 11 Q 7 9 R d 4 <br />California Integrated Waste Management Board —_.____ . <br />-Part A - Survey BLUE OR BLACK INK PEN <br />TPID - <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 />i <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />/� <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Inspection Type (Fill one) <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Site Suffix: <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />r <br />Q <br />�� <br />TPID - <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 />i <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />/� <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Inspection Type (Fill one) <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Site Suffix: <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive 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 />Routine <br />Q Re -inspection <br />Q Referral <br />Q Observation <br />Local - - <br />Identifier. j Ci_ l.t <br />l <br />Y'_ <br />if Referral, choose referral type (Fill one) <br />; fi: r <br />( :. <br />Q CHP Q <br />CIWMB Q Complaint <br />Q Educational <br />Visit Q Other <br />Business or Facility Name <br />�r✓i�,_� <br />- <br />Inspected By <br />- <br />Inspector <br />Physical Address <br />-FIT, <br />! <br />I J <br />f C <br />1 u vJ <br />Street _ <br />r. ! <br />ck my, <br />1 <br />Inspection <br />Date <br />r "� <br />/ 6_,.; 0 -2 <br />I <br />City <br />Business Rep <br />State ZIP Code <br />Title -} <br />Time In <br />[TO AM <br />Time Out <br />[TO <br />AM <br />0 PM <br />0 PM <br />Operational Status Tire Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE) <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />a Active <br />Q Passenger <br />Q Generator <br />Q Outdoor <br />--- O <br />Q Closed <br />Q Altered <br />Latitude <br />GPS <br />Q Hauler <br />Q Indoor <br />i <br />Q Inactive <br />Q Truck <br />1 <br />D <br />Longitude - <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler Q Agriculture Q Shredder @ Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V A HAULING 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 - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive 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 />Comments <br />N <br />Q Dismantler Q Tire Derived Fuel <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />Q In Compliance - No Violations <br />Inspection Form Included: Q - <br />Comments Included: Q <br />Business Rep's Signature Phone Number Inspector's Signature <br />INSTRUCTIONS ON BACK Correct:* incorrect: X Ai v/ I E X I A Mi P, j E, 11 2x31 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />Phone Number <br />62081 <br />