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nspection Report Number
<br /> :.. Waste Tire Spy & Inspection Repor _p _-
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<br /> �, State of California Survey Form - Page 1 - { v I
<br /> CIWMB 181(New 04104)
<br /> California Integrated Waste Management Board
<br /> s BLUE OR BLACK INK PEN
<br /> Part A- Survey
<br /> Buslne, P pfile ' --
<br /> TPID- Inspection Type (Fill one)
<br /> 1 � t
<br /> Site Suffix: / J u �� ! f a^ ti� # Routine Q Re-inspection Q Referral Q Observation
<br /> Locals; If Referral,choose referral type(Fill one)
<br /> Identifier: {,jt; ��r; (j�yi (� ,i Q CHP Q CIWMB Q Complaint Q Educational VisitFQ Other
<br /> Business or Facility Name Inspected By Inspector
<br /> ..f.
<br /> - I T/
<br /> Physical Address
<br /> i, I -
<br /> 1
<br /> Street p
<br /> / Ins ection Date ! �;
<br /> L-- f State ZIP Code Time In Time Out
<br /> City —
<br /> Business Rep Title m AM
<br /> !/ l 0 PM O PM
<br /> A -
<br /> Imam"�y
<br /> O erational Status �1 r,�r"�� Business Role
<br /> (Fill one only) (r� �, � � (Fill all that apply)
<br /> Ire,Count,WhollelPTE (7 ���,� , F N
<br /> Q Active
<br /> t,V "t' �� a ("�a",' Q Generator
<br /> _TUf > P"''kd Par f
<br /> ML
<br /> t��,� Q Hauler
<br /> PSLatitudeGQ Inactive
<br /> @'Closed
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<br /> O � w 4 aJ�wzF Prow '
<br /> + t4 hw�tira"xa�a ,�a atx > '^ QEnd Use r�
<br /> Longitude – Q Planned � 1' `mr;
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<br /> ,
<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 HAULING AND MANIFEST'REQUIREMENTS Q Notice Of Violation Q Extension
<br /> 11 Q 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 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 I 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 ('a(.i I a..; } t;: - ( i t ( tf.
<br /> U ✓
<br /> Inspection Form Included: Q
<br /> Comments Included: Q - _-
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: X
<br /> ip,
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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