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Waste Tire S & Inspection Re ` Inspection Report Number ■
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<br /> State of California Y � � -- 7
<br /> CIWM8181(New 04/04) Survey Form - Page 1 1 Q 10 6 8 7 i
<br /> California Integrated Waste Management Board __
<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> TPID- 1 f.' / Inspection Type (Fill one)
<br /> Site Suffix: /J. ! I �.% r ® Routine Q Re-inspection 0 Referral 0 Observation
<br /> Local �s j If Referral,choose referral type(Fill one)
<br /> Identifier: /.'!j,.' tib lei{ �: + O 0 0 p 0 0 Other
<br /> ( C i. + CHP CIWMB Complaint Educational Visit
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<br /> Business or Facility Name Inspected B
<br /> r •'" P y Inspector
<br /> Physical Address ( ILt
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<br /> Sit eel p [CT) �
<br /> Ins ection Date
<br /> City State ZIP Code Time In Time Out 0 AM
<br /> Business Rep Title O0 AM F] ]
<br /> PM 0 PM
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<br /> Operational Status a Business Role StlgType
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<br /> �+ Active ® Generator
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<br /> 0 New Tire Dealer 0 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
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<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> j V w A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<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 Date
<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 or EXT)
<br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years —
<br /> I
<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 /> 0 In Compliance - No Violations
<br /> 0 0 Other: §
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<br /> _. 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect ( �;: 11 U r, g^E 2T�i"
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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