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Waste Tire Su. Inspection Report-Number
<br /> State �y & Inspection Report_-pj� _/ Ay
<br /> California� CIWM f181 New Survey Form - Page 1 V Y 6 4 L 1 '
<br /> CIWMB 181 New 04/04)
<br /> 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: I _ ` Q Routine Q Re inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name d i Inspected By Inspector
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<br /> Physical Address
<br /> Street
<br /> Inspection Date ) �,
<br /> I ( -' / State ZIP ode i Time In Time Out
<br /> City F: - --
<br />' Business Rep �-� Title O AM O AM
<br /> C_� _.� ' MOPM ' � OPM
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<br /> Operational Status r z �, Business Role ) '
<br /> � (Fill one only) � � (' pl�+ (Fill all that apply) `�� " �
<br /> -
<br /> �� �
<br /> Q Active Q Generator
<br /> O
<br /> Q Closed I r f,4�a>ate ra
<br /> GPS Latitude � . (K) Hauler
<br /> Inactive
<br /> p Q
<br /> Longitude 111 Q End-UseQPlanned
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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 ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline
<br /> O O
<br /> PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB m m m
<br /> Q Q 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred(CIWMB Enforcement,
<br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> 0 In Compliance - No'Violations
<br /> Q '
<br /> Q Q' 0 Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK
<br /> Correll Incorrect. ' J eYMN L 62081
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<br /> White Copy:6WMB Yellow Copy:Operator Pink Copy:LEA
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