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■ Waste Tire Son& Inspection Repor _nspection Report Number ■
<br /> State B California
<br /> Survey Form - Page 1 _- e
<br /> CIWMB 181(New 04/04) g
<br /> California Integrated Waste Management Board
<br /> Part A- Surve i0 BLUE OR BLACK INK PEN
<br />} TPID- _ Inspection Type (Fill one) "
<br /> Site Suffix: {� —1 ® Routine Q Re inspection Q Referral Q Observation
<br /> Local 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 Inspected By Inspector
<br /> INPhysical Address
<br /> Street Ell
<br /> Inspection Date
<br /> I
<br /> City State ZIP Code Time In Time Out _.
<br /> Business Rep Title0 AM 0 AM
<br /> � � _ 0 P � � £ �, QPM
<br /> r Operational Status ; ,w Business Role
<br /> N3C °w' P 7 t ay✓l P e 4/ �
<br /> (Fill one only) / ( (Fill all that apply) it
<br /> l ® Active ® Generator 4�
<br /> O Q Closed w" r
<br /> GPS Latitude = . 17-TTI-I Q Hauler
<br /> D Q Inactive
<br /> r �1�
<br /> Longitude — Q Planned Q End Use „ �M
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<br /> 5 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 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 m / 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 rorQC;T)
<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 Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: � ,�,. A`;� P LE� �»l B � ` 62os1
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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