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<br /> Waste Tire ey & Inspection Rep Inspection Report Number
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<br /> State of California j
<br /> CIWMB181(New04/04) Survey F-orm - Page 1 5 3 3
<br /> California Integrated Waste Management Board - _ ___ _ ._._
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> Buslne r- ,r ) w„ rtepeistion Defaits
<br /> TPID- _ 7E Inspection Type (Fill one)
<br /> Site Suffix: tr / n Routine 0 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 /> F>'
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address /
<br /> Street Inspection Date
<br /> city State ZIP Code Time In Time Out
<br /> Business Rep Title =
<br /> 0 AM 0 AM
<br /> O PM O PM
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<br /> Operational Status I �,YJnY¢r Business Role
<br /> (Fill one only) IIIA �("P ' 1 (Fill all that apply) aJe �l fit(hat 's
<br /> ® Active . srre 3 Generator
<br /> � O Q Closed
<br /> GPS LatitudeF771
<br /> r (et11w" wn j i ' M�rH,w� '" `„ Q Hauler
<br /> D Q Inactive irT� iF
<br /> Longitude — Q Planned ��rrw +at Q End-Use
<br /> �� ��7'iw rwa"F�?a
<br /> iP,^� ,"a� ,re nru t M�.s
<br /> x r ✓rIN'R RE
<br /> Q New Tire Dealer Q Auto Repair ® 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
<br /> eHauleRg sE dransport of Tires
<br /> AND MANIFESTREQUIREMENTS
<br /> r QRMEN S Q Notice Of Violation Q Extension
<br /> Q Q
<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
<br /> 0 , 0 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 O - - -
<br /> 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 ® In Compliance - No Violations
<br /> Q Q Other: § - -
<br /> Comments
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<br /> INSTRUCTIONS ON BACKAk
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