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M " ®a Waste Tire SuA &Inspection Repor inspection Report Number <br />>«� CIWMIState f( <br />CIWMB 181 Californiaf New 04/04) <br />California Integrated Waste Management <br />Board Survey Form <br />-Page 1 <br />1. 8- X 0 0 8 0 0 8 <br />PRC §42951 - Waste Tire Hauler Registration and Transport of Tires <br />Part A - Survey <br />BLUE OR BLACK INK PEN <br />Business Profile <br />'m <br />Inspection Details <br />TPID - <br />Site Suffix: <br />0 P <br />O <br />qj <br />Tire Type <br />71 <br />� <br />Q <br />- <br />[�J2 <br />(Fill all that apply) <br />(Fill all that apply) <br />( Inspection Type (Fill one) <br />0 Active <br />0 Passenger <br />O Generator <br />0. Outdoor <br />31 <br />t Closed <br />0 Altered <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />lC) <br />O <br />Other: § <br />6) Routine 0 Re -inspection O Referral 0 Observation <br />Local <br />Q Inactive <br />If Referral, choose referral type (Fill one) <br />Identifier: <br />0 Planned <br />O CHP 0 CIWMB . O Complaint 0 Educational Visit Q Other <br />Business or Facility Name <br />0 Container <br />Inspected B <br />p y. Inspector <br />Physical Address <br />Street <br />--" ""^ <br />Inspection Date <br />City <br />Business Rep <br />State ZIP Code <br />Title <br />Time In Time Out <br />O AM 0 AM <br />Tire Count (Whole/PTE) [1, I I I I ' = <br />U <br />GPS Latitude <br />I 1 10 <br />Longitude - I I I I. <br />Business Type (Fill all that apply) <br />Q New Tire Dealer 0 Auto Repair O Trucking Fleet O Government O Retreader <br />0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station O Hauler O Agriculture 0 Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />m'm0PM <br />0 <br />O <br />PRC §42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />'m <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 P <br />O <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />Q <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 Active <br />0 Passenger <br />O Generator <br />0. Outdoor <br />'0 <br />t Closed <br />0 Altered <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />lC) <br />O <br />Other: § <br />Q Hauler <br />indoor <br />Q Inactive <br />0 Truck <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />Q New Tire Dealer 0 Auto Repair O Trucking Fleet O Government O Retreader <br />0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station O Hauler O Agriculture 0 Shredder 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 />0 <br />O <br />PRC §42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />Q <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />0 <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />,Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />'0 <br />14 CCR § 18461 - Manifest. System Requirements for Waste Tire End -Use Facilities <br />Q <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />lC) <br />O <br />Other: § <br />I Comments <br />Dismantler O Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date m/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />O In Compliance - No Violations <br />Inspection Form Included: <br />Comments Included: <br />Business Rep's Signature Phone Number Inspector's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct: Incorrect:) 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ® ■ <br />f <br />