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Waste Tire Su & Inspection Reportonspection Report Number, t
<br /> °"•�'"• State of California i a
<br /> CIWMB181(New 04/04) Survey Form - Page 1 1 73 9
<br /> California Integrated Waste Management Board ! J L- -- - --
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> 01 0 'ay r ��( r � aro . 'a tu t t� a rrrI rl
<br /> TPID- � _ Inspection Type (Fill one)
<br /> Site Suffix: t (0 Routine 0 Re-inspection Q Referral Q Observation
<br /> Local a If Referral,choose referral type(Fill one)
<br /> Identifier: :`•` O CHP Q CIWMB O Complaint O Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address -- _-.___�__ I L.—�_-1 L��J._=_1.._'___J _.. - �° ' '-•\ 0
<br /> L� w
<br /> Street Inspection Date
<br /> I - ., ;• � I' Time In
<br /> City State Z/P Code Time Out�}
<br /> Business Rep Title : F0 AM _T PM O PM
<br /> �;'�'a-�Mr�rla r "fir M -
<br /> Operational Status;tro Irf et *rt" Business Role �GYf
<br /> (Fill one only) (Fill(Fill all that apply)E
<br /> ":: �,�al�gr M(rr��
<br /> O Active f' ,r" 'Mr"a ! Q Generator
<br /> Imam
<br /> Latitude O ® Closed
<br /> GPS � �} ra qui./aa�r 0 Hauler 4?� rahw
<br /> " y ry
<br /> Q Inactive
<br /> Longitude - O Planned r End Use
<br /> Eery P"tea,wp +y
<br /> �wX1r fir a a
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<br /> O New Tire Dealer 0 Auto Repair O Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer Q Auto Body ® Car Dealer O Collection Q Crumb Rubber
<br /> Q Service Station O Hauler O Agriculture Q Shredder O Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS `
<br /> A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension
<br /> O0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> M / M / m
<br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators. In Compliance - No Violations {
<br /> i
<br /> O 0 Other: § - _!
<br /> Comments -
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: l , , P L � , 2 g I 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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