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Waste Tire Sully & Inspection Repor Inspection Report Number
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<br /> CIWMIfCaliforniaSurvey Form - Page 1 � - G CIWMB 181(New 04/04)
<br /> California Integrated Waste Management Board - -- --
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> TPID- _ -y � ; Inspection Type (Fill one) �
<br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> I :
<br /> Physical Address
<br /> Street -- l El
<br /> 7 Inspection Date
<br /> City State Zip Code Time In _ Time Out
<br /> Business Rep Title AM 0 AM
<br /> 0 PM 0 PM
<br /> Operational Statusralr1,M Business Role!
<br /> (Fill one only) � t�iI� (Fill all that apply) �4° t1� 1tt1fC?l)
<br /> ® Active 1 ? �G ��(` ® Generator 7 td for
<br /> rt trr yay7p rvV""r a�n: is '" wka ( r r r
<br /> 0
<br /> 0 Closed
<br /> Latitude � 4u ify+t
<br /> GPS Q Hauler an�IQdC
<br /> LL 1 0 y r��d (rrt
<br /> inactive
<br /> a
<br /> Longitude
<br /> 0 End Use
<br /> on ' 6�rt1r
<br /> 9 0 Planned
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<br /> New Tire Dealer (j) Auto 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 IREQUIREMENTSRegistration
<br /> dTransport of Tires 0 Notice Of Violation 0 Extension
<br /> I I
<br /> 0 O § g
<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 0 '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 orEXT)
<br /> '
<br /> 0 1 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 ® In Compliance - No Violations
<br /> 0 0 Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct C ° , ,Incorrect: , p 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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