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Spection Report Number
<br /> Waste Tire Surft & Inspection Report
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<br /> State of California
<br /> CIWMB181(New04/04) Survey Form - Page 1 , 1 0 - i 0 13 53 i
<br /> - California Integrated Waste Management Board ..... .-.. -
<br /> Part A- SurveyBLUE OR BLACK INK PEN
<br /> .spec on Detatls -
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: ' fEE - ,r j j
<br /> Routine Q Re inspection Q Referral Q Observation
<br /> Local _ If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> C.1
<br /> Physical Address
<br /> Street --�
<br /> Inspection Date © / =j ,
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<br /> City State ZIP Code Time In_ Time Out
<br /> Business Rep r` Y Title 0AM 0 AM
<br /> 7 ' � E70PM = ' = 0P
<br /> Operational Status hr +, Business Role
<br /> (Fill one only) ill�)) (Fill all that apply)
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<br /> Q Active � t BF r ® GeneratorMEMEH: :room kil ,rani r�
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<br /> Q Closedm
<br /> GPS Latitude = . E L_j
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<br /> 6" rhe rh'�G'„"yt4�r;"�r Q Hauler
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<br /> p. Q Inactive /nor ) n�n 1
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<br /> Longitude - 0r1 /,hyo Q End-Use Cn Q DtIItC? �
<br /> Plannedn
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<br /> 10 i1111111 11 11;�Iill�!!!=11�1 Ll mm�
<br /> ra(4 New Tire Dealer Q Auto Repair Q Trucking Fleet Q`Government Q Retreader Q Dismantler Q Tire Derived Fuel
<br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS
<br /> V ' A HAULING AND MANIFEST REQUIREMENTS ® Notice Of Violation Q Extension
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<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0--
<br /> 14 CCR§18459.1 (a)(b)(c) Tire Program ID Number from CIWMB
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT)
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years I
<br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities i' r
<br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> O O Other:
<br /> Comments f
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect �\� �/ X A M I_ E- l 1 2 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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