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.1 <br />Waste Tire SuuuuuuuO# & Inspection Repor pection Report Number <br />OR <br />State of California -- -_--- -�- -_-- -- ■_ <br />CIWMB 9st(New <br />Manag) Survey Form - Page 1 ! 9 - 1 V 3 � 0 1� <br />California Integrated Waste Management Board <br />Part A - Survey BLUE OR BLACK INK PEN <br />TPID - r. Inspection Type (Fill one) <br />Site Suffix: @ Routine Q Re -inspection Q Referral Q Observation <br />Local If Referral, choose referral type (Fill one) <br />Identifier: <br />(, C' Q CHP O CIWMB Q Complaint O Educational Visit Q Other <br />Business or Facility Name <br />7 Inspected By Inspector <br />Physical Address <br />/V1C <br />Street <br />— Inspection DateEo: E <br />amity jV State ZIP Code Time In Time Out <br />Business Rep Title J % AM0 AM <br />® PM l f ®PM <br />Operational Status, a�t Business Role Fill_one only) iii til "�11� (Fill all that apply) 6 <br />p <br />��ri r,?,)' <br />( Active ����`ef1 r t Generator <br />Latitude <br />0 Closed; � �d <br />GPS F] <br />iir yr �t r �, Q Hauler <br />C O Inactive F 1 �wM ° ° INN",t <br />i u }4� r a Y 9'e <br />Longitude — . <br />FI—T] <br />-End=Use 0 Planned �„ s <br />O New Tire Dealer O Auto Repair @ Trucking Fleet 0 Government Q Retreader <br />0 Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br />Q Service Station Q Hauler 0 Agriculture Q 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 />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <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 />Q <br />Q <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 />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments J <br />fl)t� i V ;'_t.( j / Cyt:) d 1'y'lQ✓C;tt".l�j. <br />Dismantler 0 Tire Derived Fuel <br />INSTRUCTIONS ON BACK Correct:* Incorrect: X ,"� V E-_ XLA IAIP'L .L�� _ 62081 <br />■ .. White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA © ■ <br />