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Inspection Report Number
<br /> Waste Tire Su&y & Inspection Report-State __
<br /> ooa
<br /> CIWMB
<br /> f81(New SurveyForm Page 1 �_ 7 - 1 0 10 7 7 1_
<br /> CIWMB 181(New 04/04)
<br /> California Integrated Waste Management Board -- -
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: J L/ `/ t' ( - 0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local _ If Referral,choose referral type(Fill one)
<br /> Identifier: '
<br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address
<br /> �i t �
<br /> i E
<br /> Street Inspection Date
<br /> city State ZIP Cade Time In Time Out
<br /> Business Rep Title % O AM m O AM
<br /> 0 PM 0 PM
<br /> i Operational Status ad b , / �� Business Rolea �
<br /> (Fill one only) (Fill all that apply) t,
<br /> �Y Active f� � � � Q Generator a�"� ov rl� '�«k !r � a�+ a r yr dy+r"m"•'nry r.
<br /> ay^,.
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<br /> C
<br /> Latitude air �a
<br /> GPS �Y r 0 Hauler77
<br /> �® Inactive ���
<br /> O � 4 �aat
<br /> Longitude - 0 Plannede "u f End-
<br /> 47
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<br /> III �
<br /> NO
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<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber
<br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS
<br /> A :'i HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m m
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> _
<br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ; In Compliance - No Violations
<br /> 0 0 Other: § .:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X 1 , L�
<br /> A p 1721-31 62081
<br /> ■ -- -- ® ■
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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