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<br /> Waste Tire Su y & Inspection Repor Inspection Report Number ■
<br /> ..,683.x.. State of California
<br /> CIWMB 181(New 04/04) Survey Form Page 1 1 0 0 0 7 3 3 1��
<br /> California Integrated Waste Management Board J ------- -- ---- -- -- -
<br /> Part A- Surye BLUE OR BLACK INK PEN
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<br /> TPID- Q G ; I Inspection Type (Fill one)
<br /> Site Suffix: 1 . i Routine Q Re-inspection Q Referral Q Observation 1
<br /> Local !� 1 If Referral,choose referral type(Fill one)
<br /> Identifier: `r+ 1Ii 1 r (t.l fl 1, (}►it y°: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
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<br /> Business or Facility Name
<br /> Inspected By Inspector
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<br /> Physical Address � i t„_
<br /> Street i^ i E Inspection Date
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<br /> City State Zip Code Time In Time Out
<br /> Business Rep Title AM ;® AM
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<br /> Operational Status Business RoleMEE :E
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<br /> GPS Latitude Q Hauler r��r� � ✓�� "r"�✓1�
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<br /> Longitude - Q Planned � � �„� '� O End Use &� ) "✓
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<br /> Q New Tire Dealer Q Auto Repair U: 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 Q Other
<br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> i/ A 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 /> 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 m m
<br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q 10 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> O O Other: --
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<br /> Comments
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<br /> Inspection Form Included: Q
<br /> Comments Included: Q p, 9 P ,
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X X;
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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