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Waste Tire S e
<br /> y & Inspection Repor 'inspection Report Number
<br /> ® - 'I State of California " -....... .,_-,... .-.-... .._. I ■
<br /> Survey Form - Page 1 1 1 0 13 0 2 8
<br /> CIWMB 181(New 04104)
<br /> California Integrated Waste Management Board --- ---- --- -- - ---
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> Business Profile Inspection Details
<br /> TPID- ++ Inspection Type (Fill one)
<br /> Site Suffix: I I tl/ �( I ` i 0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local �" j If Referral,choose referral type(Fill one)
<br /> Identifier: ;, ;,J r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> { � t: t''��t
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> ! Inspection Date
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<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title m 0 AM i O AM
<br /> 0 P 0 P
<br /> LW' titi(f
<br /> Operational Status p t Business Role Type
<br /> Storage T e
<br /> (Fill one only) Ir �ttki "� � (Fill all that apply) (Fill all that apply)
<br /> - � .� i �N"yr'"�� i P R�'N t rp✓"��h�'"aC
<br /> Active t tegr;rr 0 Generator 0 Outdoor
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<br /> 0 Closed 0 Hauler
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<br /> Latitude �
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<br /> 0 New Tire Dealer 0 Auto Repair Q 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 Q Notice Of Violation 0 Extension
<br /> – — --- –
<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 1 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 orE)(T)'
<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 I 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 /> ® In Compliance No UiolaUons
<br /> 0 0 Other: § r„t, irk � at ” M: ✓ t , ., ,
<br /> Comments r
<br /> r
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<br /> Inspection Form Included: 0 "
<br /> Comments Included: 0
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect:
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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