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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 />Waste Tire <br />Su%y & <br />Inspection Report nspectionReport Number <br />_= $ StWMB11(Nate of rnia <br />CIWMB 181 (New 04/04) <br />California Integrated Waste Management Board <br />Survey <br />Form -Page 1 i <br />Q <br />fl 7 <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Part A - Survey <br />Q <br />-- -� <br />BLUE OR BLACK INK PEN <br />Q <br />inspection Details <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />TPID - <br />Site Suffix: <br />Q <br />2 <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 />Inspection Type (Fill one) <br />1Other: § <br />Comments 1 <br />Q Routine Q Re -inspection Q Referral Q Observation <br />Local <br />If Referral, choose referral type (Fill one) <br />Identifier: j: <br />�� <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <br />Physical Address <br />------- ----- <br />f `- <br />r <br />Inspection Date <br />/ <br />Business Rep <br />ZIP C ode <br />In Time Out <br />_ <br />O AM <br />m O AM <br />StateTime <br />Title <br />: <br />m <br />QPM QPM <br />m - <br />Operational Status -Tire Type '' Business Role orage Type <br />Tire Count {Whole/PTS <br />(Fill one only) (Fill all that ap ,, (Fill all that apply) III all that apply) <br />Q Active Q Passenger Q Generator Outdoor <br />O 1 ® Closed Q Altered <br />Latitude <br />GPS <br />Q Hauler Q Indoor <br />O Q Inactive Q Truck <br />Longitude— <br />Q Planned Q OTR Q End -Use Q Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer Q Auto Repair <br />Q Trucking Fleet <br />Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer Q Auto Body <br />Q Car Dealer <br />Q Collection Q Crumb Rubber <br />Q Service Station Q Hauler <br />Q Agriculture <br />Q Shredder Q 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 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire 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 />1Other: § <br />Comments 1 <br />r � <br />1 <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 Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X � �; ,N � . ,aa, F I L I E E C 3 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />