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ft,Waste Tire S Inspection Re oil ction Report Number
<br /> State of California
<br /> CIWMB 181(New 04/04) Survey Form - Page 11 8 - 1 Q Z 5 8 9 4
<br /> California Integrated Waste Management Board ....... ._-.
<br /> Part A Survey BLUE OR BLACK INK PEN
<br />} TPID- �.,_., - -�f'}� Inspection Type (Fill one)
<br /> SSuffix: �j
<br /> ite ! lJ t (�Routine Q Re-inspection Q Referral Q Observation
<br /> LocalIf Referral,choose referral type(Fill one)
<br /> Identifier: _ V1 1L qlA{V1 -I y O CHP O CIWMB O Complaint O Educational Visit O Other
<br /> Business or Facility Name f Inspected By Inspector
<br /> Physical
<br /> AddressL1dI v Y.t k1_ I z
<br /> Street
<br /> (� Inspection Date
<br /> City State ZIP Code I Time In Time Out
<br /> Business Rep i Title 0 AM 0 AM
<br /> O PM O PM
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<br /> „ Operational Status Business Role
<br /> (Fill one only) /' (Fill all that apply)
<br /> e Active (&Generator
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<br /> O Q Closed �4a
<br /> GPS LatitudeELI
<br /> H
<br /> 110 Q Inactive auler
<br /> LongitudeO Planned End Use r r,
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<br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel
<br /> O Used Tire Dealer Q Auto Body O Car Dealer O Collection O Crumb Rubber
<br /> Q Service Station Q Hauler O Agriculture Q Shredder ® Other ' Pct t _ �, �tt ��{ (yt pct
<br /> f .-,---------1 _,_C ..,
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IENFORCEMENTSTATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O Q PRC§42956-Registration/Decal in Vehicle
<br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB M / FTI / M
<br /> O Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> O Q 1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
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<br /> O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> ( N Viaton
<br /> In Compliance
<br /> 10 0 Other: §
<br /> Comments {. 1 r
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<br /> INSTRUCTIONS ON BACK Correct: yWincorrect: - I" � I� P L 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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