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Waste Tire .vey & Inspection RepLe. Inspection Report Number <br />State of California <br />CIWMB181 <br />Waste <br />eManag) Survey Form - Page 1 1 l - 10 02_5_ _7 0 41 <br />California Integrated Waste Management Board _. <br />'art A - Survey BLUE OR BLACK INK PEN <br />TPID - <br />Site Suffix: <br />V <br />U <br />HAULING AND MANIFEST REQUIREMENTS <br />O Routine Q Re -inspection O Referral <br />Q Observation <br />Local <br />Identifier:,1 <br />C I <br />r1 i j <br />Inspected By Inspector <br />0 <br />�J lJ N <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />Business or <br />Facility Name <br />JE" � <br />Physical Address J <br />Scree. J <br />State ZIP Coa <br />Business Rep Title <br />It <br />Tire Count (Whole/PTE) <br />O <br />GPS Latitude I ( I <br />1i—l—li--10 <br />Longitude <br />Q New Tire Dealer Q Auto Repair Q Trucking Fleet <br />Q Used Tire Dealer Q Auto Body Q Car Dealer <br />Q Service Station Q Hauler 0 Agriculture <br />Inspection Details <br />V <br />Inspection Type (Fill one) <br />HAULING AND MANIFEST REQUIREMENTS <br />O Routine Q Re -inspection O Referral <br />Q Observation <br />If Referral, choose referral type (Fill one) <br />0 <br />Q CHP Q CIWMB Q Complaint O Educational Visit O Other <br />Inspected By Inspector <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />JE" � <br />� <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 />0 <br />Q <br />Inspection Date El <br />Q <br />Time In Time Out <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 AM <br />0 AM <br />0PMIT-]'m <br />QPM <br />Operational Status Pre Type Business Role <br />Storage Type <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />0 Active O Passenger <br />O Generator <br />O Outdoor <br />Q Closed 0 Altered <br />Q Hauler <br />oor <br />i <br />Q Inactive O Truck <br />It <br />0 Planned QJ,OTR 0 End -Use <br />ntainer <br />Government <br />Q Collection <br />Q Shredder <br />Retreader <br />Q Crumb Rubber <br />Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <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 />0 <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 />O <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Other: <br />0 <br />0 <br />§ <br />Comments 1 <br />0 Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />0 In Compliance - No Violations <br />Inspection Form Included: Q <br />Comments Included:- – - <br />; Business Rep's Signature Phone Number Inspectc <br />INSTRUCTIONS ON BACK Correct: Incorrect: X /;- \/ � X 'A 14FPTC[�F[711213 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />