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<br /> Waste Tire Sufty & Inspection Repor ` Inspection Report Number
<br /> State of California - __ ■
<br /> S54 y CIWMB181(New04/04) Survey Form - Page 1 Q Q ,
<br /> California Integrated Waste Management Board �.,
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> f Site - 1 .I � T - Inspection Type (Fill one)
<br /> Site Suffix: I �� �- I (� (jl Routine Q Re-inspection Q Referral Q Observation
<br /> Local % 1 If Referral,choose referral type(Fill one)
<br /> Identifier: ' Tf t
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<br /> 0", (7 �; ;;{ ; L O CHP Q CIWMB O Complaint O Educational Visit O Other
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<br /> Business or Facility Name - - -
<br /> Inspected By Inspector
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<br /> Physical Address
<br /> I 1 V" ' I
<br /> Street
<br /> Inspection Date /� DU
<br /> UT.) /UU
<br /> City T State ZIP Code Time InTime Out
<br /> Business Rep Title FT
<br /> Q AM Q AM
<br /> Q PM �� Q PM
<br /> a Mr
<br /> Operational Status M,a Business Role (' +
<br /> (Fill one only) 1✓ �a (Fill all that apply)
<br /> L V f Y� �y'� ���rr�'6r� /"I k �l h C✓�,'" r ul�.�
<br /> Active t � � (a Generator tp� r �rrbl
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<br /> GPS Latitude FTT7 O Closed �1 i� d 1'
<br /> C Q Inactive ^�� t �'rr7r��'r�r
<br /> Longitude - 0 Planned � 0 End Use ®� r
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<br /> Q New Tire Dealer O Auto Repair O Trucking Fleet O Government O Retreader Q Dismantler O Tire Derived Fuel
<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber..
<br /> O Service Station O Hauler O Agriculture Q Shredder Other C d j
<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 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Notice Of Violation Q Extension
<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 0 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 /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> 0 Q 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
<br /> 2 In Compliance - No Violations
<br /> 0 O I Other: §
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<br /> Comments J, -
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect t 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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