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<br /> ■ Waste Tire St&y & Inspection Repo r Re Inspection art Number ■
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<br /> State California Survey Form - Page 1 -
<br /> • CIWMBB 181(New 04/04)
<br /> California Integrated Waste Management Board 11
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> TPID- n i � �., – ( Inspection Type (Fill one)
<br /> Site Suffix: i ("f ,; I'�� � � �' (� Routine Q Re inspection Q Referral Q Observation
<br /> Local 1 / If Referral,choose referral type(Fill one)
<br /> Identifier: C t'1 �'"' ^ p 0
<br /> fL U 1-t_ CHP CIWMB Complaint Educational Visit Other
<br /> Business or Facility Name -
<br /> Inspected By Inspector
<br /> Physical Address ,
<br /> Street
<br /> ^i Inspection Date l :7
<br /> (. j1
<br /> City �, ; State ZIP Code Time In Time Out _
<br /> Business Rep Title
<br /> AM 0 AM
<br /> ED : 0 PM M— : IT_1 0 PM
<br /> a
<br /> Operational Status s� Business Role
<br /> (Fill one only)_ �, ;' ��. (Fill all that apply)
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<br /> V Active Q Generator
<br /> GPS Latitude O Closed
<br /> 0 Hauler
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<br /> Lon itude – r,
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<br /> g Q Planned '�>� 0 End Use
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<br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O 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
<br /> Q Notice Of Violation 0 Extension
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 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`orEXT)
<br /> O 1 O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - --
<br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CIWMB Enforcement
<br /> Q 0 1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations M
<br /> Q Other: §
<br /> Comments 1 j
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<br /> Comments Included: 0'
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: X - T ti ,µ.ii { . 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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