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Ins ection Report Number
<br /> State of California
<br /> X Waste Tire Su _ _p _ p _.
<br /> �y & Ins Inspection Re or'
<br /> I I r! r
<br /> CIWMB181(New 04/04) Survey Form Page 1
<br /> California Integrated Waste Management Board Y - �J --- - ---- --- --- --
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- + N_ - --- `Inspection Type (Fill one)
<br /> Site Suffix: I I ? % ( �; ' ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local i- ,'' If Referral,choose referral type(Fill one)
<br /> Identifier: (r,y t !. f+} ,;l / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name f Inspected By Inspector
<br /> f.
<br /> Physical Address
<br /> Street p 1 l
<br /> � Ins ection Date � 1 L-• � ,
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title I �l O AM m O AM
<br /> 0 PM I�J I m 0 PM
<br /> i
<br /> Operational Status a r F Business Role
<br /> Y wit M1 r r
<br /> Fill one only) 7 !°I� all that a I l c
<br /> ( Y) FIII rw � � � �� (
<br /> Q Active �r s9tw Q Generator,"�y[� �tq�/�
<br /> - O Q Closed
<br /> GPS Latitude wQHauler- FT 1 a+,w1aC fi�r""uPo a r l� �*)rap �✓,rzt
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<br /> tt t W b +~r
<br /> (§1Inactive
<br /> End-UseLon
<br /> Longitude Q Planned Iti�g lT�p
<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 a Car Dealer Q Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other
<br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A jHAULING AND MANIFEST REQUIREMENTS
<br /> 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. Compliance Deadline
<br /> i
<br /> IQ Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m
<br /> Q Q 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 EXT)
<br /> Q O — — —
<br /> 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 /> IQ 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
<br /> 0 In Compliance - No Violations
<br /> Q IQ Other: §
<br /> Comments .. l
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect. F I✓1 B 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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