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Waste Tire Su ey & Inspection ReportoOpection Report Number
<br /> State of California I -- _-- - - j
<br /> CIWMB 181(New 04104)
<br /> California Integrated Waste Management Board Survey Form - Page 1 (i �J(� f O V�f'�j i/j/A� ,{j 3 i 3 i
<br /> Part A-Yw aSurve BLUE OR BLACK INK PEN
<br /> fNM
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: j � -� —
<br /> Routine Q Re-inspection Q Referral Q Observation
<br /> Local I If Referral,choose referral type(Fill one)
<br /> identifier: �i(%� 1 tt� ( ��)�• ti Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name 4, -
<br /> Inspected By Inspector
<br /> SIP
<br /> Physical Address - ;
<br /> Street - -
<br /> Ins ection Date
<br /> rr p
<br /> I M 17_.�
<br /> City State ZIP Code Time In _ Time Out
<br /> Business Rep Title Q AM 0 Am
<br /> --� • �_ 0 P � • 0 P
<br /> Operational
<br /> I Status it ype µ Business ole Storage Type
<br /> ( only) ( �tappi )j (Fill all that apply) (- at apply)
<br /> %yM Q Active Q Passenger Generator Q Outdoor
<br /> GPS
<br /> Latitude • �� �O O Closed Q Altered
<br /> Q Hauler Q Indoor
<br /> O Q Inactive Q Truck Longitude - Q Q End Use Q Container
<br /> Planned Q OTR
<br /> Business Type (Fill all that apply)
<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 I0 Agriculture Q Shredder # Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFOt2GEME'NT STATUS �, '
<br /> _. .
<br /> V A `HAULING 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 /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 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 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 1 Q Referred/CIWMB Enforcement
<br /> 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 /> Q Q Other: § t'&alai, i'4„ �rtt'ftk'' I a1
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<br /> INSTRUCTIONS ON BACK ,'Correct:* Incorrect: XA M11��L � � � � 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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