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Waste Tir'6u46y & Inspection R*r Inspection Report Number
<br /> State of MB181i(New Survey Form ' Page 1� V L V { L# L
<br /> CIWMB 181(New 04/04) '
<br /> California Integrated Waste Management Board
<br /> Part A- Survey r. BLUE OR BLACK INK PEN
<br /> � frefr
<br /> ,�',,:? Mir% � �' -
<br /> TPID- Inspection Type (Fill one)
<br /> I Site Suffix: O Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local _ If Referral,choose referral type(Fill one)
<br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> I T, Inspected By Inspector ;
<br /> RPhy sic �al Addr¢s
<br /> ��,/
<br /> sJ
<br /> �- /�
<br /> Street j _
<br /> Inspection Date
<br /> ' T
<br /> 1 �; t 1?�9 Lit�C<Gc
<br /> City State Zip Code Time In Time Out
<br /> Business Rep Title � l , F-7 O PM Q AM
<br /> L_.__ J -- - 0 P
<br /> Operational Status
<br /> Business Role
<br /> (a Active Generator
<br /> Fill
<br /> w,r�rhf i�rire u,( oneony) (Fill all that apply)
<br /> n,
<br /> Latitude Q0 Closed
<br /> GPS
<br /> „„Yre
<br /> '
<br /> g,.
<br /> O Hauler
<br /> 0 inactive
<br /> Longitude — it' ,< 0 End-Use
<br /> 0 Planned
<br /> 0 New Tire Dealer ( ,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
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility � ENFORCEMENT STTTTT w' `"
<br /> -= --
<br /> V ' A HAULING AND MANIFEST REQUIREMENTS
<br /> 0
<br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension
<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 lfor NOV orEXT)
<br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 I 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred t 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 /> Q, I❑ CompFiance - No Violations
<br /> 0 0 Other: §
<br /> Comments / JI
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<br /> INSTRUCTIONS ON BACK Correct:� Incorrect � � ,� ;I�y �� � ���� � 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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