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t8V7304618S ■ <br />fit <br />Waste Tire Survey &State CailftrnlInspection Report Inspection eportNumber <br />rr CIWM 181(New Survey Form - Page 1 F1 8. 1 0 1 0 8 4 7 <br />C8NM8 181 (New 04104) <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID -, O D Inspection Type (Fill one) <br />Site Suffix: G 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local % If Referral, choose referral type (Fill one) <br />Identifier: C1t74�te y �/ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Na-�meae Inspected By Inspector <br />Physical Address J z ;,a L <br />I <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 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 />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />Street <br />0 <br />Inspection Date <br />City <br />Business Rep <br />State ZIP Code <br />Title <br />Time <br />In <br />O AM <br />Time Out <br />Q AM <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />:Fi <br />O PM <br />EII: O PM <br />Tire Count/ (WholelPTE) <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />_ <br />Operational Status <br />(Fill one only) <br />Tire Type '• <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />1 0 <br />Other: § <br />Comments <br />. <br />® Active <br />Rye <br />Passenger <br />0 Generator <br />0 Outdoor <br />GPS Latitude <br />O <br />I , <br />0 Closed <br />0 Altered <br />0 Hauler <br />®Indoor <br />Longitude — <br />I <br />' . L <br />11 <br />11 <br />O <br />0Inactive <br />0 Planned <br />Q Truck <br />0 OTR <br />End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer 0 Auto Repair <br />0 Trucking Fleet 0 Government <br />0 Retreader 0 Dismantler <br />0 Tire Derived Fuel <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 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 />0 <br />0 <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirementsfor Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />1 0 <br />Other: § <br />Comments <br />Rye <br />Inspection Form Included: I 'all rJ <br />Comments Included: — 'all <br />Business Rep's Sigp t e Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correet: Incorrect: 62081 <br />White Copy: CIWMB Yellow Copy. Operator Pink Copy LEA <br />