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■ Waste Tire oby & Inspection.,ReporQrnspection Report Number
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<br />' State of California - {� yam,
<br /> California
<br /> y g 1 1 V 1 3 1 3 V
<br /> CIWMB 181(New 04/04) Survey Form - Page 1
<br /> California Integrated Waste Management Board - j
<br /> Pad A Survey BLUE OR BLACK INK PEN
<br />} TPID- � - � Inspection Type (Fill one)
<br /> Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: <</ f-" -! Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name - -
<br /> - -- Inspected By Inspector
<br /> 4
<br /> _..
<br /> Physical Address
<br /> F _ f
<br /> Street Y/-
<br /> �j - Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title /
<br /> Q PMM O PM
<br /> MME I Operational Status Business Role y r F
<br /> 'r ^,m(Fill one only) ( fir (Fill all that apply) ri )
<br /> Active e Generator
<br /> GPS Latitude Q Closed / rof
<br /> ' 100
<br /> ���r �r� �*aM���� T Q Hauler
<br /> Inactive
<br /> —O aM�; "�n�r"rmr✓ tr a�
<br /> t
<br /> Longitude Q End-Use
<br /> QPlanned
<br /> f
<br /> .� °ice"✓ra'" ..lti,a.�;. '�._.1k -
<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 / 1'i s
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<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A I HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q ExtensionQ § Hauler
<br /> IRegistration
<br /> d 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 Datum
<br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q I Q 14 CCR§ 18459:2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days
<br /> (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 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
<br /> I ® In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: i 1 ^ 62081
<br /> incorrect: k I
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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