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<br /> �- Waste Tir&ySu1 & Inspection Repospection Report Numberrt I-_
<br /> '•' "'- State of California
<br /> CIWMB181(New 04/04) Survey Form - Page 1 �_ 1 1 ! 8 5 18
<br /> CaliformaIntegrated Waste Management Board —
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br />} TPID- Inspection Type (Fill one)
<br /> i Site Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 1� -`�� , t ��a Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> ��^`-•1 � r-•�r- Inspection Date
<br /> ( t > c State ZIP Code i Timet.� In_ Time Out --
<br /> Business Rep Title QAM : F
<br /> Q AM
<br /> QPM O PM
<br /> Operational Status frp ',,nf,t. Business Role7T
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<br /> (Fill one only) f, )1IW (Fill all that apply)
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<br /> Active �> ® Generator
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<br /> Longitude - Q Planned Q End Use ( ,
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<br /> O New Tire Dealer O Auto Repair O Trucking Fleet O Government Q Retreader Q Dismantler O Tire Derived Fuel 11
<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber
<br /> O Service Station Q Hauler O Agriculture Q Shredder O Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A 1 HAULING AND MANIFEST REQUIREMENTS
<br /> 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 /> O O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 1:11 / m /
<br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB EEI
<br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> O 014 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 Q Referred CIWMB Enforcement
<br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 O : 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators to Cgmpllance Na Vlolat►ons
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<br /> Comments
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<br /> == 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: , E'
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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