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■ Waste Tire S&ey & Inspection Repo - Inspection Report Number
<br /> State
<br /> CIWMB
<br /> f 81(New
<br /> Survey Form - Page 1 „-, - 3 0_2
<br /> -_
<br /> CIWMB 181(New 04/04) � �
<br /> California Integrated Waste Management Board .__ _-.-_-_ -_-_,. _.
<br /> Part A Survey BLUE OR BLACK AC INK PEN
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<br /> TPID- i Inspection Type (Fill one)
<br /> Site Suffix: 1
<br /> �� 0 Routine 0 Re-inspection 0 Referral Q Observation
<br /> Local -- ; ) If Referral,choose referral type(Fill one)
<br /> Identifier: J { r( t �,�� •� �� l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name_ Inspected By Inspector
<br /> Physical Address (� c,
<br /> Street t {
<br /> L'ick iU�`� Inspection Date
<br /> II Time City State ZIP Code me In Time Out
<br /> Business Rep Title 0 AM 0 AM
<br /> 0 11 �) LI'd L ® PM 0 P
<br /> 1
<br /> 'Operational Status Business Role f
<br /> (Fill one only) tkl e�l' fb (Fill all that apply) ptf{/ etty)
<br /> ��k�rr'rfrWbi,✓,tl,°�j 9/ lb 'an,�✓t+�ur
<br /> 0 Active � � {"rid @ Generator
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<br /> 0 Closed
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<br /> Latitude ��” t%,r u� stn 0 Haulerl i r l�Fl�l
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<br /> Planned 0 End-Use
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<br /> EM
<br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> @ 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 STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 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 I Date 0 m m
<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 for NOV orEXT)
<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 0 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 ® In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments terr"`- I II
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect:,X y
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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