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<br /> ■ Waste Tire Su & Inspection Report spection Report Number
<br /> - _ - _ _ - ■
<br /> car s StateCalifornia Survey Form - Pagel - 1 Q 3 7
<br /> CIWMB181(New 04/04)
<br /> California Integrated Waste Management Board — ._ . . ..........._ __ ---_-._ -
<br /> Part A B hSurvey BLUE OR BLACK INK PENr'�ta'(r�'
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<br /> TPID- — — Inspection Type (Fill one)
<br /> I Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Localj If Referral,choose referral type(Fill one)
<br /> Identifier: (L C)6 C/tv,l i { !;{ 'L' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address
<br /> Street T
<br /> 1 f: Inspection Date
<br /> City State ZIP Code Time In _ Time Out
<br /> Business Rep Title rAM0 AM
<br /> LU �i C� PM PM
<br /> av *,
<br /> Lo—
<br /> Operational StatusBusiness Role
<br /> vpri �,,ai �I
<br /> (Fill one only) �,{�, ,N ) 'fit4t1 (Fill all that apply)
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<br /> Active ^, ' yn f� Q Generator ►Qt r
<br /> ,Y �,Va iad "r a�atr� k l€��. �'""�M,^r� i "}a'�1h�, >�^'•'7� aw
<br /> Q r c rS v"v� as arN r ar f au' ^
<br /> Closed
<br /> Latitude
<br /> 0 Hauler
<br /> 0 Inactive
<br /> Longitude 0Planned ) 0 End-Use
<br /> 5 fid
<br /> ON ew Tire Dealer 0 Auto Repair (a 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 STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice°Of Violation 0 Extension
<br /> 0 0 11PRC§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
<br /> 0 0 14 CCR§18459.1 (a)(b)(c) The Program ID Number from CIWMB M / M / m
<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 Referred/CIWMB Enforcement
<br /> 0 0j 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ✓a "� �`" �� "x't
<br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators t
<br /> 0 0 Other: §
<br /> Comments i " )[
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<br /> INSTRUCTIONS ON BACK Correct;( Incorrect. , ,. L_ y 62081
<br /> ■ Copy: , ti ® ■
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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