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AWaste Tire SuSby & Inspection Report Inspection Report Number
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<br />State of California '
<br />■i�9 CIWMB 181 (New 04/04) Survey Form - Page 1 i U _ t V
<br />California Integrated Waste Management Board ----- -
<br />Part A - Survey BLUE OR BLACK INK PEN
<br />Business Profile In$pectrcwt�#t�,w " /ria 1 'A
<br />TPID - r.11
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<br />Inspection Type (Fill one)
<br />Site Suffix: % t J
<br />Routine Q Re inspection Q Referral Q Observation
<br />Local/ If Referral, choose referral type (Fill one) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br />Identifier: is
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<br />s or Facility Name ' Inspector
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<br />Bushes i Inspected By
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<br />Physical AddressF/ T�. J
<br />Street f'l Inspection Date)
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<br />TiimeIn _ Time Out
<br />Business Rep Title � ; ��� 0 AM
<br />0 PM 0 AM EL ' O PM
<br />Operational Status ri" ►pt / Business Role
<br />(Fill one only) (Fill all that apply)
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<br />GPS Latitude,�'rtr,'f(., Q Hauler
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<br />� UseLongitude Q Planned Q End
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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
<br />V A I HAULING AND MANIFEST REQUIREMENTS
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<br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires
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<br />PRC § 42953 - Contracts with Registered Waste Tire Haulers.
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<br />PRC § 42956 - Registration/Decal in Vehicle
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<br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements
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<br />! 14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB
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<br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days
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<br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years
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<br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers
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<br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities
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<br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators
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<br />Other: §
<br />Comments ;
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<br />ENFORCEMENT STATUS
<br />Q Notice Of Violation Q Extension
<br />Compliance Deadline
<br />Date m/m/m
<br />(Required for NOV or EXT)
<br />Q Referred/ CIWMB Enforcement
<br />Q In Compliance - No Violations
<br />(i'i C i t Ott ry
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<br />Inspection Form Included: Q
<br />Comments Included: -
<br />Q, Business Rep's Signature Phone Number Inspector's Signature Phone Number
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<br />INSTRUCTIONS ON BACK Correct:0 Incorrect: X V , 1.0, '_ p
<br />62081
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<br />■ White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA ■
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