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Ins ection Repo Number
<br /> Waste Tire Suzy & Inspection Reporft___p _p
<br /> '9 State of California
<br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 1 0 1 3 5 2 0
<br /> California Integrated Waste Management Board --- --
<br /> PartA- Survel BLUE OR BLACK INK PEN
<br /> TPID- (.. Q QFi _ _, i Inspection Type (Fill one)
<br /> Site Suffix: ' lv �� Routine Q Re-inspection Q Referral Q Observation
<br /> Local r If Referral,choose referral type(Fill one)
<br /> Identifier: {V'1 cl Cd( {,{;r_ t ��,_.� L; I Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name `' �' Inspected By Inspector
<br /> _ /
<br /> Physical Address (j 7 r'
<br /> Street Inspection Date
<br /> 1
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title O PM m , m O PM
<br /> I'A(J U �iA6`( U)Y l ��
<br /> Operational Status tr�E apt ;^ '�r r Business Role
<br /> Q (Fillone only) (Fill(Fill all that apply)
<br /> Q Active �ritgt "$i Q GeneratorIr� r�l
<br /> 0 ®Closed E7�+ .I ' G(rr J' # P"�gi"nra6 � '�r➢�'/ar'E:.
<br /> GPS LatitudeHauler
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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 Q 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 Q
<br /> Q Q Notice Violation Extension
<br /> 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 Q mM
<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 (Requited forNOV 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 Q Referred/CIWMB Enforcement
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q 1 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> In Ctampltance No �/�olat+arrs
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect X �;. N/ = �A Aj c I 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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