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FY4:, spection Report Number
<br /> Waste Tire Sunk & Inspection Report ■
<br /> V3333 State of California
<br /> ® CIWMB181(New 04/04) Survey Form - Page
<br /> California Integrated Waste Management Board �.J �_.e 1 - 1 ..-.
<br /> Part A Suryey BLUE OR BLACK INK PEN
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<br /> Site - Inspection Type (Fill one)
<br /> ff C�
<br /> Site Suffix: ` t —� „ (31)Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local �r—� �.�'— J If Referral,choose referral type(Fill one)
<br /> Identifier: 1
<br /> � .�-• �/:-.,tit- rY-(w ; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> r } Inspected By Inspector
<br /> Physical Address [� 0 �..�-� !�
<br /> Street
<br /> Inspection Date
<br /> Cit
<br /> y State ZIP Code Time In _ Time Out
<br /> Business Rep Title O AM 0 AM
<br /> O PM -[1] 07! 0PM
<br /> Operational StatusBusiness Role � �)�
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<br /> (Fill one only) (Fill all that apply) � ( � ✓ I
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<br /> 0 Active n , 0 Generator � t {'✓r
<br /> ( PS Latitude 0 %Closed /✓^�'Garlri��tr�r
<br /> h✓iiia 0 Hauler rd"rY'.�rretF`rk✓rf�a"rt�a4>r�y���'!�/'''r+)VI�aryt 4✓Y!+ntry�a�"
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<br /> 0 Inactivei����
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<br /> Longitude — '; � � 0 Planned �� �' "�) 100 0 End Use
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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 /> k'_? 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 1, ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS 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 Date m /-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 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 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 r` / /
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<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct: incorrect:
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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