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Waste Tire Sdfty & Inspection Repooe Inspection Report Number
<br /> *IDE's° State of California ` , - - ---- ---- ■
<br /> IDID CIWMB 181(New 04/04) _
<br /> California Integrated Waste Management Board Survey Form - Page 1 1 8 - 1006473
<br /> Part A Survey
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<br /> TPID- �!nspectionType (Fill one)
<br /> Site Suffix:
<br /> a Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Q CHP
<br /> Identifier: Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> -- I Inspected By Inspector
<br /> Physical Address
<br /> Street I
<br /> Inspection Date
<br /> City State Zip Code I Time In Time Out
<br /> Business Rep Title
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<br /> QPM
<br /> IL
<br /> 'operational Statusk�T� T +r� Business Role
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<br /> Q New Tire Dealer QAuto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derive
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<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q
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<br /> Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q AgricultureQ
<br /> Shredder Other
<br /> Q
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<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility �EN-F'
<br /> ORCEMENT STATUS
<br /> -li
<br /> V A HAULING AND MANIFEST'REQUIREMENTS _ - - -
<br /> _ .
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension '
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers.
<br /> 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 / m
<br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m
<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 Q Referred/CIWMB Enforcement
<br /> Q 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 /> Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
<br /> Inspection Form Included: Q, — — --
<br /> Comments Included: Q.
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X t XjA A", i 62081
<br /> - © ■
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA
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