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® Waste Tirevey°& Inspection Rep „Inspection Report Number
<br /> fi=7I_ State of California � I� x
<br /> g=�= CIWMB 181(New 04/04) Survey Form - Page 1 1_, _ � . � � � � 4 � �
<br /> California Integrated Waste Management Board .-- .-- � - . --
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> f",� 7 A r ry 7 r r "z 5^l a „✓ rr` r �^rf"i �✓vNvPuk� d �F A5 'r's C rrii ' r � l �rC �
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: - ! Eli _�1 0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local � I If Referral,choose referral type(Fill one)
<br /> Identifier: �11 10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address -
<br /> .l
<br /> Street / /
<br /> Inspection DateEE H]Time In Time Out EE
<br /> Ctv State ZIP Code _ __
<br /> Business Rep Title 0 AM �AM
<br /> !j �® PM
<br /> LJ_J 0 PM
<br /> Y
<br /> Operational StatusBusiness Role
<br /> (Fill one only) r,1i >^ (Fill all that apply) �r111Pptktaa (Ir
<br /> 0 Active to 1r � 0 Generator D ctatdcor ,
<br /> O 0 Closed
<br /> �+ Latitude
<br /> GPS �rtr rrurlrir rr"iF AArr �A I� � Hauler
<br /> i 0/I�l4�CYryrF Fir
<br /> inactive �' hCtG2�o�r '+""
<br /> .�.. .�
<br /> r r ( 0 End Use In o fare rI
<br /> � Planned
<br /> Longitude r F" Y: rryytM r +r � n
<br /> meq rW"NR)r� �"rd/r'rr l^�n t 8rvF ��Fni ^ '�
<br /> 1N'R
<br /> 0 New Tire Dealer 0JAuto 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 0 Other _
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> O I1 -1 0 0 Notice Of Violation 0 Extension
<br /> 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
<br /> 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 /> 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
<br /> 0 In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK I(Correct:*~Incorrect: '("v �/ YV M' I� I ! 2 31 62081
<br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA
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