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Waste Tire S.Aey & inspection Repor'll Inspection Report Number
<br /> ® j State of California ._, ..........-j ■
<br /> y �nm Survey Form - Page 1 Ll- 4 - 1025899 _
<br /> CIWMB 181(New 04/04)
<br /> California Integrated Waste Management Board - -- -- -
<br /> Part A- Surve BLUE OR BLACK INK PEN
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<br /> TPID- l Inspection Type (Fill one)
<br /> Site Suffix:
<br /> I � � � Routine Q Re-inspection Q Referral Q Observation
<br /> Local C"t �- /v If Referral,choose referral type(Fill one)
<br /> Identifier: JC t c �'(� ` {;;(,tt l_ i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name V Inspected By Inspector
<br /> Physical Address
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<br /> Street
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<br /> Inspection Date ; C./
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<br /> City State ZIP Code Time In _ Time Out
<br /> Business Rep Title O AM O AM
<br /> � • �0PM � ' 0 P
<br /> ala„Operational Status % ti Business Role
<br /> (Fill one only) (Fill all that apply) °
<br /> �„C'"'�ar4�:'�'"7�;��✓�° �w<:'�rri"�'� f ,��Y�
<br /> Q Active )/� Q Generator
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<br /> Latitude D ® Closed
<br /> Q Hauler �
<br /> _ Q Inactive
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<br /> Q End-Use (,
<br /> Longitude — Q Planned
<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q=Government Q Retreader Q Dismantler r 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 rl HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q.Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
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<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 m
<br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m 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 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 Referred!CIWM6 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
<br /> Q Q Other: §
<br /> Comments
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<br /> ( - .m_.� �T �._:_ I 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X r
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<br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA
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