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Waste Tire SuSby & Inspection ReportInspection Report Number ■
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<br /> i State of California
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<br /> CIWMB 181(New 04/04)
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<br /> iforniaIntegrated Waste Management Board Survey Form - Page 1 ( 1 J 7 J 4 _1
<br /> Part A- Surve BLUE OR BLACK INK PEN
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<br />} TPID- - Inspection Type (Fill one)
<br /> Site Suffix: J '} �V / / zr: Routine Q Re-inspection Q Referral Q Observation
<br /> Local //,-f If Referral,choose referral type(Fill one)
<br /> Identifier: (�j;? (jt f G''CT; 1 t. l; _M Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
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<br /> Physical Address? -
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<br /> Inspection Date
<br /> City State ZIP Code Time in Time Out
<br /> Business Rep Title AM J O AM
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<br /> Operational Status„ a M,r Business Role
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<br /> GPS Latitude Q Hauler
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<br /> Longltude
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<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 6) Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<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. i Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date m / m / m
<br /> 00 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 EX)
<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 Z In Compliance - No Violations
<br /> Q Q Other: §
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<br /> INSTRUCTIONS ON BACK Correct:* incorrect: `,-/ 1 X AM P 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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