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Waste Tire S & Inspection Reporspection Report Number
<br /> State RRRR';S3
<br /> CIWMBf 81(New Survey Form - Page 1 1 r 1 0 1 3 3 3 1
<br /> CIVIIMB 181(New 04/04)
<br /> California Integrated Waste Management Board _. _ ...
<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> TPID- (( / Inspection Type (Fill one)
<br /> Site Suffix: Q (0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local 1,�� If Referral,choose referral type(Fill one)
<br /> Identifier: r ; -'� `f�/7 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> ---
<br /> Business or Facility Name -
<br /> ''-- i Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> City ' State ZIP Code Time In Time Out
<br /> Business Rep Title 0 AM 0 PM J= ' 0 AM
<br /> 0 PM
<br /> Operational Status Tire Type Business Role Storage Type
<br /> Tire Count Whole/PTEA (Fill one only) (Fill all that apply) (Fill all that apply) (FIII all that apply)
<br /> a ® Active 0 Passenger ",, 0 Generator 0 Outdoor
<br /> GPS Latitude Closed 0 Altered +^
<br /> ® Hauler 0 Indoor
<br /> _— D 0 Inactive 0 Truck
<br /> Longitude - 0 Planned O OTR 0 End-Use 0 Container
<br /> BI.icines !ype (Fill all that apply) '
<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 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 /> 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 /> i
<br /> O O
<br /> PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m-/ 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 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 O In Compliance - No Violations
<br /> 10 0 Other: §
<br /> Comments '-�I --(-
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<br /> INSTRUCTIONS ON BACK Correct: incorrect: lip
<br /> 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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