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<br /> _ Waste Tire Sur�y & Inspection Report', on -
<br /> y9& State of California
<br /> CIWMB181(New 04/04) Survey Form - Page 1 t 4 - 10 10 5 7 u '
<br /> California Integrated Waste Management Board - -�--- - --- --- - -----f
<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> Business Profile 140 01Mr
<br /> Site Suffix: � t� � �-) t` f - (�'ti � Inspection Type (Fill one)
<br /> SiteTPI - 1 1� Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local ` i If Referral,choose referral type(Fill one)
<br /> Identifier: Z " a I j( t `t / f
<br /> \ J1 (,�(, ✓f L''.I "'I 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> _ Inspected By Inspector
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<br /> Physical Address _ I r I
<br /> Street i
<br /> f i -_,l"' ) ,. -�, •-, Inspection Date
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<br /> Time In Time Out
<br /> City State ZIP Code __
<br /> Business Rep Title O AM O AM
<br /> k 0PM � � �t__.i 0PM
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<br /> �.. Operational S " ,+ Business Role
<br /> Fill one only) Fill all that apply)
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<br /> Tire Count(V'l4hol60' 't
<br /> ( Y) '(1 #ltl4iI apl ( �
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<br /> 0 Actives0 Generator
<br /> -T O aule
<br /> 0 Inactive
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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 /> 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 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
<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 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 0 In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments .
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<br /> Inspection Farm-included: 0
<br /> Comments Included: 0
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: _' t c
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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