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spection Report Number
<br /> � Waste Tire Sury & Inspection Report n_ ___-- �
<br /> .3
<br /> State of California
<br /> CIWMB181
<br /> Waste
<br /> eManage) Survey Form - Page 1 J 1 0 47 _9
<br /> $
<br /> California Integrated Waste Management Board -.-_.. --_.
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> Bus4n
<br /> TPID- _ Inspection Type (Fill one)
<br /> Site
<br /> Site Suffix: r, 7 O Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: �� 4- Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector �
<br /> Physical Address 6. ( y
<br /> iiai .7� __ J
<br /> Street �__�
<br /> Inspection Date � � / o
<br /> City State ZIP Coe Time In _ Time Out
<br /> Business Rep Title Q AM
<br /> � ]OAM
<br /> 0PM � � � QPM
<br /> Operational Status( r r �� Business Role
<br /> (Fill one only) OtfT � (Fill all that apply)
<br /> rr > "n�
<br /> l.J (�Active ��� I�S�CS��t �iJ�r, �Generator
<br /> 0
<br /> F d aNN y "M {N 'twWrVr},, ryPF� J
<br /> Closed
<br /> Latitude rd � iw J O Hauler s
<br /> �
<br /> 0 !0 Inactive
<br /> Longitude — y) '"1 r
<br /> Planned µ sr a y End Use
<br /> it �a ' ��;,
<br /> ) ,
<br /> Q New Tire Dealer QW Auto Repair O Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber
<br /> O Service Station O Hauler O Agriculture Q Shredder (2)'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 /> Q Notice Of.Violation Q Extension
<br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q O PRC§42956-Registration/Decal in Vehicle
<br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / F[I / M
<br /> 0 O 14 CCR§'18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> O O Other:
<br /> Comments
<br /> �� .� �..
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: XI ' �/ F .x762081
<br /> ■ - : ® S
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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