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■ Waste The Su- y & Inspection Repor _ nspection Report Number
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<br /> State of California
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<br /> rsaazs CIWMB181(New 04/04) Survey Form - Page 1 1 1 0 1 3 3 2
<br /> California Integrated Waste Management Board __._.--_
<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> - �i Inspection Type (Fill one)
<br /> Site Suffix: L -_- -l T �f v l -
<br /> ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> LocalIf Referral,choose referral type(Fill one)
<br /> Identifier: , 1,; t CIOr`' f; 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
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<br /> Business or Facility Name -
<br /> --� Inspected By Inspector
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<br /> Physical Address
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<br /> Street
<br /> c^ r� t Inspection Date
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<br /> City State Zip Code Time In Time Out
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<br /> Operational Status ( a'r "T'a�a1! Business Role ( r/
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<br /> 0 Closed
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<br /> 0 Hauler �a � rrdr t/
<br /> p 0 Inactive
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<br /> Longitude ! 0 Planned ;� a ' 0 End-Use (i
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<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader (a 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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. v Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Ell / [11 11:1
<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 Q 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/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 /> INSTRUCTIONS ON BACK 4Correct:i -Incorrect: X-/�;, k '; , "I'M p 'LlEl 11, 1213 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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