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<br /> Waste Tire Sulby & Inspection Reporinspection Report Number
<br /> State of California _. 1 ._. A-.. ■
<br /> CIWMB 181(New 04/04) SurveyForm - Page 1 1 3r4
<br /> California Integrated Waste Management Board �J .. -.- _ .. ,--._..� _ ...-.
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> �7,1
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix ( T�j Routine Q Re inspection Q Referral Q Observation
<br /> Local - If Referral,choose referral type(Fill one)
<br /> Identifier: ' 'rt :?< cC.r �� !.£7,E.�z- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Nam e
<br /> Inspected By Inspector
<br /> L I /I
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<br /> Physical Address P E "L2
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<br /> Street
<br /> Inspection Date
<br /> G State !ZIP Code Time In Time Out
<br /> Business Rep Title O AM AM
<br /> 1
<br /> ,. _� PM
<br /> Operational Status Tire Type fp Business Role Storage Type
<br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that.apPl#,
<br /> (a Active Q Passenger Q Generator Q Outdoor
<br /> O QClosed Q Altered Q a
<br /> Latitude Hauler Indoor
<br /> Q Inactive Q Truck
<br /> Longitude - Q Planned Q OTR Q End-Use Q Container
<br /> Business Type (Fill all that apply)
<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel
<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q 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 I HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> Q @ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q @ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m O FT] / m
<br /> Q 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
<br /> (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 Q in Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> Inspection Form Included: Q
<br /> Comments Included: Q, -
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: \/ 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator RPink Copy:LEA _-
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