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Waste Tire Survey & Inspection Report Inspection Report Number ■ <br />�r State of California <br />CIWM8191 <br />California Integrated Waste Managemanl Hoard <br />Survey Form - Page 1 1 <br />8- 1 0 1 0 8 2 2 <br />IteInag.J <br />'art A - Survey _ <br />O <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Q <br />Inspection Dotalt9 <br />• <br />TPID -/ / <br />Site Suffix: <br />' l - O / <br />`r <br />Inspection Type (Fill one) <br />Routine Q Re -inspection <br />Q Referral Q Observation <br />Local (i <br />Identifier: 62Qf Li <br />If Referral, choose referral type (Fill <br />Q CHP Q CIWMB Q Complaint <br />one) <br />Q Educational Visit Q Other <br />Business or Facility Name <br />/ �s <br />Physical <br />Q Container <br />Inspected By <br />InsP actor <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 />Inspection Date Q -% <br />e / Q <br />Business Rep <br />Title <br />Time In <br />0 AM <br />Time Out <br />0 AM <br />Q <br />1 Q <br />0 PM <br />O PM <br />- <br />Operational Status, Tire Type <br />Business Role <br />Storage T ype <br />Tire Count (Whole/PTE) f <br />Sr D <br />� <br />(Fill one only) (Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />G PS Latitude <br />Longitude - <br />Business Type (Fill all that apply) <br />0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />0 Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />W Active <br />Jill Passenger <br />W Generator <br />i Outdoor <br />O <br />Q Closed <br />Q Altered <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />• <br />Q Inactive <br />Q Truck <br />Q Hauler <br />Q Indoor <br />O <br />Q Planned <br />Q OTR <br />Q End -Use <br />Q Container <br />Business Type (Fill all that apply) <br />0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader <br />Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br />0 Service Station Q Hauler Q Agriculture Q Shredder Q Other <br />Part <br />B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />MENEM <br />Q <br />Q 1 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 />1 Q <br />1 Other: § <br />Dismantler Q Tire Derived Fuel <br />Comments— '3r i ,tcs gS 2)a2 �dd� GeJG1/4if <br />7 �^ <br />ar J,;7e 8(,?t� Ojw4 <br />Inspection Form Included: Q <br />Comments Included: Q — -- 7 <br />Busines p's ignature Phone Number Inspectors Signature. Phone Number <br />INSTRUCTIONS ON CK G �(�■ P E 5 2 62081 f; ' .ten. Y ...e 3 ® ■ <br />White Copy: CIWMB Yellow Copy. Operator Pink Copy: LEA <br />tl^ '-i A4•A1ff <br />