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Waste Tire S *11 & Report Inspection R rt� spection Report Number
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<br /> Sr36y�� St _
<br /> ate of California '
<br /> CIWMB181(New 04/04) Survey Form - Page 1 t_ 4 .- '1, 0 1 3 4
<br /> California Integrated Waste Management Board . -. -
<br /> Part A- S BLUE OR BLACK INK PEN
<br /> nspection Details
<br /> TPID- ? - _ Inspection Type (Fill one)u W 4
<br /> �'Site Suffix. / / / 0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local + If Referral,choose referral type(Fill one)
<br /> Identifier: of(� {t��i'��j-C �t r'_ la
<br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address
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<br /> x i v c o ,l Y
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<br /> Street
<br /> Inspection Date
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<br /> - - r I Time In
<br /> city State ZIP Code mTime Out_ _.
<br /> Business Rep Title 0 AM / 0 AM
<br /> 0 PM ( Q PM
<br /> Operational Statusf Business Rolet )
<br /> r>r" i rr tit+l �
<br /> { (Fill one only) p ( (Fill all that apply) irM Ir II^st# �
<br /> it Q Active /� �1 � (T y Q
<br /> Generator �1+ca,ri`t it
<br /> Latitude D 0 Closedr� a � ry��1ta
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<br /> GPS � i W��a�� ,rr�,� ki 0 Hauler
<br /> Inactivef5 ,
<br /> Longitude - 0Planned ii,, 0 End Use i 0
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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 Q Other A/1 f iA i.(l�t /lll( 1 q
<br /> V A I ENFORCEMENT STATUS
<br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility
<br /> Part
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<br /> HAULING AND MANIFEST REQUIREMENTS
<br /> Notice Of Violation 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 pate
<br /> m ; m
<br /> I, 0 0 14 CCR§ 18459.1 a b c Tire Program ID Number from CIWMB m
<br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days
<br /> (Required for NOV or EXT)
<br /> 0 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 /> 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 0 Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK rCorrect:* Incorrect: ; �/, � S",� I_ 1u 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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