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Inspection Report Number
<br /> Waste Tire Su-*by & Inspection Report ■
<br /> -� " State of California .� '
<br /> Gii.88 CIWMB 181(New 04/04) Survey Form - Page 1 10 0 7 1 t
<br /> California Integrated Waste Management Board -- --- --- --
<br /> Part A- Survev
<br /> } BLUE OR BLACK INK PEN
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<br /> Site Suffix7✓""^m+'�leRoutine
<br /> outine s1y ' Q Po Re-inspection
<br /> 0
<br /> _ Referral Q�:.." O
<br /> . bservat.i_o..�nTPID- Inspection Type (Fill one) .�
<br /> Local 1 %y If Referral,choose referral type(Fill one)
<br /> Identifier: ,} Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Cl J -
<br /> Inspected By Inspector
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<br /> Physical Address
<br /> Street
<br /> Inspection Date
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<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title a]0 AM M EE
<br /> O PM 0 AM
<br /> PM
<br /> °- �� �_ Operational Status r" �a�arG( Business
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<br /> Latitude q
<br /> k Q Hauler
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<br /> Longitude — Q Planned ' End Uses
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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
<br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> — - - - -_.
<br /> V A `:HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and 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 Date
<br /> Q Q
<br /> 14 CCR§18459.1 (a)(b)(c)-The Program ID Number from CIWMB M / M / Ffl
<br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (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 0 In Compliance - No Violations
<br /> Q Q Other: § — ---- - _
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' 1 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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