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Waste TirWuy & Inspection R Inspection Report Number
<br /> ® 'r» State of California
<br /> CIWMB181(Now
<br /> 04/04) Survey Form - Page 1 - 3 1 0 2 7 3113
<br /> California Integrated Waste Management Board
<br /> Part A Survey y BLUE OR BLACK INK PEN
<br /> specpny,btal
<br /> TPID Inspection Type (Fill one) -
<br /> Site Suffix: �.) J > f -
<br /> @ Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: O CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address C�
<br /> F/ 211< I fit:.: -./���
<br /> � // _ � / "
<br /> Street
<br /> Inspection Date G /
<br /> City State ZIP Code Time In _ Time Out
<br /> Business Rep Title � AM O AM0PM � � 0 P
<br /> J
<br /> Oerational Status r �ia� usiness Role ' oto " rw
<br /> _ p ,ay a ,Vayr
<br /> (Fill one only) of � �(� (Fill all that apply)
<br /> Active " � i Q Generator ✓t }, IgyCyrrs
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<br /> O O Closed
<br /> Latitude
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<br /> GPS ��
<br /> Hauler
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<br /> Q Inactive
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<br /> Longitude Planned
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber
<br /> O Service Station Q Hauler O 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 Notice Of Violation Q 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 /> Q O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> m m
<br /> 0 Q 14 CCR§18459.1 a (b) c -Tire Program ID Number from CIWMB 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> Q O O In Compliance - No Violations
<br /> 01 O Other: § _ — - — _ — -
<br /> Comments ` 1
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<br /> INSTRUCTIONS ON BACK I Correct: : Incorrect. i P
<br /> ® White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA
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