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Waste Tire Surve,& Inspection Report ospection Report Number ■
<br /> State of California
<br /> CIWM6181(New04/04) Survey Form - Page 1,
<br /> California Integrated Waste Management Board __..__. .....-_ 0 0 $_.__ -_..
<br /> Part A Surve BLUE OR BLACK INK PEN
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<br /> TPID- r Inspection Type (Fill one)
<br /> Site Suffix: E�1i
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<br /> f � � � Routine Q Re-inspection Q Referral Q Observation
<br /> Local ;� ,i i If Referral,choose referral type(Fill one)
<br /> Identifier: 4t !
<br /> -.,,;.. °.:t �+-Lp') �.._.: 'r�t Y�,,• �. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
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<br /> Physical Address --)
<br /> Street
<br /> Mr Inspection Date
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<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title (D AM
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<br /> Operational Status r rr r ""N" Business Role
<br /> (Fill one only) i° (Fill all that apply)
<br /> ® Active r Generator
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<br /> - 0 Q Closed to/ ?) + rrfl /t' t�Iwu4w�,'t"�a r
<br /> Latitude
<br /> µ Q Hauler40
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<br /> Q Inactive fl" tea ., r/y ✓ fYr
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<br /> Longitude — �f�T sr"apa)� fil Q End-Use
<br /> Planned � I af� � r""r" taaat%a �"arid r
<br /> Business e'w t by SIS
<br /> 7�7T7Q 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 (a Otherr C1r f t,r�r{j e
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A j HAULING AND MANIFEST REQUIREMENTS
<br /> - -- --- Q Notice Of Violation Q Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m
<br /> Q 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB W
<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 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 Q Referred/CIWMB Enforcement
<br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments
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<br /> Inspection Form Included: 0
<br /> Comments included: Q
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 62081 J t.r �, ,"��, �_I I ; i._;
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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