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Waste Tire Suy & Inspection Re o*, Inspection Report Number
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<br /> �� � State of California I
<br /> CIWM6181(New 04/04) Survey Form - Page 11 0 0 0 7 8 7
<br /> California Integrated Waste Management Board _-_ -.
<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> TPID- - l� Inspection Type (Fill one)
<br /> Site Suffix: - � �l 1 Routine Re-inspection Referral
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<br /> Local �> If Referral,choose referral type(Fill one)
<br /> Identifier: /
<br /> Gt C LA t i) Lf X1.1 v!. 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 f t -
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<br /> Street
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<br /> City State ZIP
<br /> '1 � _ Inspection Date
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<br /> I 1 a J o 1 Code I Time In Time Out
<br /> BusinessRepRep Title t0 AM LL0 AM
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<br /> Operational Status 1 x / Business Role 1p aw
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<br /> (Fill one only) (Fill(Fill all that apply) FilfII`h ( (
<br /> �^ Id" �) 74 h ��a/r�6��� a�t�"��� l id J,�{�r a ✓��r n
<br /> (a Active �I 'fs� ar (9 Generator
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<br /> GPS Latitude ��:�
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<br /> i�1t ' "kw4^ Q Hauler
<br /> Q InactlVewr��t�kr( �/19 " J
<br /> Longitude
<br /> Q Planned w,�/ r Q End Use41(tN fix.
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<br /> Q New Tire Dealer 0 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 ® Other L r %} i -1
<br /> Part B - Inspection of Waste Tire Dealer, y
<br /> , Generator, Hauler and End-Use Facility
<br /> ENFORCE N7 STATt1�
<br /> V ! A HAULING AND MANIFEST REQUIREMENTS
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<br /> 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. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
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<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 li 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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> 1 i)r t,10i 01—VI 0"1 Juf I
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<br /> Inspection Form Included: Q
<br /> Comments Included: Q
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> _.,. 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ;:; , ,�y,� a�^ d 1 k I, d
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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