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® Waste Tireey & Inspection Rep Inspection Report Number
<br /> =� State of California
<br /> is Survey Form - Page 1 Q - 1 4 3
<br /> CIWMB 181(New 04/04)
<br /> California Integrated Waste Management Board ...
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> PSDes„ u� �. rZIns�ecsftrcDetails „!
<br /> Inspection Type (Fill one)
<br /> Site Suffix: y n 3
<br /> Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
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<br /> #Physical Address -
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<br /> Street r__ Inspection Date O /
<br /> City State ZIP Cade ' Time]In Time Out
<br /> Business Rep Title l L O AM 7
<br /> j 0 PM 0 PM
<br /> Q AM
<br /> Operational Status Tire Type Business Role Storage Type
<br /> (Fill one only) (Fill all that apply)? (Fill all that apply) (Fill all that apply)
<br /> ` Q Active Q Passenger ;� Q Generator 0 Outdoor
<br /> Q Closed Q Altered
<br /> GPS Latitude E- E] QHauler Q Indoor
<br /> T77DQ Inactive Q Truk--LIZ
<br /> Longitude 8 W
<br /> d � 4 " I I � J j Q Planned Q OTRc � Q End Use Q Container
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<br /> F�F,nru7,re?.
<br /> rf.wl1Q New Tire Dealer Q Auto Repair F
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<br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber q
<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 MAN9F ST-REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> Q Q PRC§42951 -Wa,�te ire 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 Mani eating Requirements Date Q / m 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 (Required for NOV or EXT)
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forfns 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 Sy'TMm 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 /> ---- -- ---._ -- - ----'
<br /> Comments I
<br /> Inspection Form Included: Q
<br /> CommentsIncluded: Q
<br /> Business Rep's'Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 1�, 1 r; A, .O., !_ i L
<br /> 62081
<br /> ® White Copy:CIWMB Yellow Copy:Operator Pink CopyLEA
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