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Waste Tire Sur*y & Inspection Report nspection Report Number <br />-••--•' State of California <br />CIWMB181(New04104) SurVeV Form - Pa e 1 - <br />California Integrated Waste Management Board ! I —.------------ --- <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile nspection Details <br />TPID - _ Inspection Type (Fill one) <br />Site Suffix: '7 f ! <br />1 Z Q Routine Q Re inspection Q Referral Q Observation <br />Local __ If Referral, choose referral type (Fill one) <br />Identifier: `� _ tom. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />Inspected By Inspector <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 />? <br /><t- <br />Physical Address. <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />I— <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Inspection Date <br />Q <br />Street <br />1 <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />City <br />Business Rep <br />State ZIP Coe <br />Title <br />Time In <br />m AM <br />Time Out <br />O AM <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />m�L <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />'.�0PM <br />Q <br />m� 0 P <br />Q <br />IF <br />7 <br />Operational Status Tire Type Business Role torage Type <br />Tire Count (Whole/PT <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply) fill all that apply) <br />Q Active Q Passenger' <br />Q Generator Outdoor <br />O (@ Closed Q Altered <br />Latitude <br />GPS <br />I� <br />. <br />Q Hauler door <br />W <br />O Q Inactive Q Truck <br />Longitude <br />— <br />Q Planned Q OTR - - <br />Q End Use Container <br />Q New Tire Dealer <br />Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />Q Used Tire Dealer <br />Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />Q Service Station <br />Q Hauler Q Agriculture 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 />Other: § <br />Comments <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date m / 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 Reps Signature Phone Number Inspectors Sr!gmtu Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect: X EXA, !, P 62081 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />