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Waste Tire Su Ity & Inspection Repor 4nspection Report Number
<br /> �ZG�S6 State of California ! a
<br /> CIWMB181
<br /> Waste
<br /> eManage) Survey Form - Page 1 t 3 - a G 4-.1 _4..9.-0__�
<br /> � California Integrated Waste Management Board --------�------- ------ - � '
<br /> Part A- Surve BLUE OR BLACK INK PEN
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<br /> - 1 L—L-e1 Inspection Type (Fill one)
<br /> Site
<br /> Site Suffix ( y; T. ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local t ! s If Referral,choose referral type(Fill one)
<br /> Identifier: %
<br /> f'• Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
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<br /> Street r ,
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<br /> City State Zll�Code Time In Time Out
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<br /> Business Rep Title
<br /> —IQAM QAM' OPM ' Ci j ® PM
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<br /> ,,, Operational Status Business Role
<br /> " (Fill one only) (Fill all that apply) " il ��� R '.
<br /> ® Active D Generator
<br /> 0...:..: O Closed �!"
<br /> GPS Latitude _ Ufa wpPfra°u rai k� a� r
<br /> Hauler
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<br /> Longitude
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<br /> O New Tire Dealer O Auto Repair Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer Q Auto Body Q, ar Dealer Q Collection O Crumb Rubber
<br /> Q Service Station O Hauler Q Agriculture Q Shredder O Other I
<br /> Part B-----In spection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V I A HAULING AND MANIFEST REQUIREMENTS :,O 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'm / m / m
<br /> O O 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required forNOV or EXT)
<br /> O O
<br /> 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 i Q Referred i CIWMB Enforcement
<br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> O @ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators iiAim"
<br /> 0 0 'Other: §, _.._.----
<br /> Comments C
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<br /> INSTRUCTIONS ON BACK Correct:* incorrect: �/ J P1. 2 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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