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Waste Tire Suy & Inspection Repor Inspection Report Number
<br /> State CIWMB
<br /> 181(NewCaliforniSurvey Form - Page 1 -- 0 1 0 7 0 4._,
<br /> CIWMB 181(New 04104)
<br /> 11
<br /> California Integrated Waste Management Board
<br /> Surve BLUE OR BLACK INK PEN
<br /> Part A
<br /> "a^ t,
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<br /> Inspection Type (Fill one)
<br /> Site Suffix: f � F �� _ Routine Q Re-inspection Q Referral Q Observation
<br /> Local ; If Referral,choose referral type(Fill one)
<br /> Identifier: yj; - i� t ! t ;tet f; _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> i Business or Facility Name 1
<br /> Inspected By Inspector
<br /> Physical Address
<br /> / r
<br /> Street / 1
<br /> Inspection Date
<br /> c r y Stat'e ZIP Code Time In
<br /> Time Out
<br /> .• ELI
<br /> _.-.Business Rep Title — jj AM 0 AM
<br /> • I� 0PM �� M
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<br /> Operational Status Tire Type Business Role Storage' 1
<br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that40 �r)z
<br /> Tire Count (Whole/PTE)
<br /> (g Active Q Passenger Q Generator Q Outdo"tt
<br /> "fr"rrrl
<br /> O Q Closed Q Altered °r y`>, ,
<br /> GPS Latitude •'� Q Hauler Q Indoors"t"""` "
<br /> O Q Inactive Q Truck L
<br /> Longitude — Q Planned Q OTR Q End-Use Q Container ")
<br /> Business Type (Fill all that apply)
<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 /> V A I 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 m
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q Q 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 I 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 Q In Compliance No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> Comments Included: Q �
<br /> Business Rep's Signature Phone Number Inspector's Signature ` "^ ; �f,�C +�„,tr�•%�
<br /> _� X _ 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect:
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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