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<br /> IctioReport Number
<br /> Waste Tire Su y & Inspection Report -_ _p -- _ -
<br /> ■ �'�mi' State of California
<br /> �¢ CIWMB 181(New 04104)
<br /> Survey Form - Page 1 1 102 5 $ 1_6-_.'i
<br /> California Integrated Waste Management Board ---- - - ---
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> TPID- - Inspection Type (Fill one)
<br /> I
<br /> Site Suffix: I Q 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 /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> Time In Time Out
<br /> City State ZIP Code _ _
<br /> O AM
<br /> Business Rep Title I Q AM
<br /> O PM O'PM
<br /> - -- t Operational Status tri rf � r : Business Role
<br /> ( y) rEt < (Fill all that apply)
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<br /> rr; Q ActiveQ Generator a ) (
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q^Government Q Retreader Q Dismantler Q Tire Derived Fuel
<br /> Q 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 Q Notice Of Violation Q Extension
<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 M / M / m
<br /> Q Q 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 or EXT)
<br /> Q O
<br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> Q Q Q In Compliance - No Violations
<br /> Q O -
<br /> Other
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect X I"� '
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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