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Waste Tire SuiQy & Inspection Report Inspection Report Number
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<br /> ® � CIWMB181(New04/04) Survey Form - Page 1 1 8 10 2 5 7 8 7
<br /> California Integrated Waste Management Board --__
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- p- _ T, f Inspection Type (Fill one)
<br /> Site Suffix: I ! ) ! l`
<br /> Q Routine Q Re-inspection Q Referral ® Observation
<br /> Local _..— If Referral,choose referral type(Fill one)
<br /> Identifier: , Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
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<br /> Business or Facility Name Inspected By Inspector
<br /> (Physical Address- _ _ __ _._ _� I /
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<br /> Street
<br /> Inspection Date
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<br /> City State ZIP Code Time In Time Out
<br /> Business RepTitle AM 0 AM
<br /> 0 PM __E : ! 0 PM
<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 /> , n (9 Active Q Passenger 4 Generator Q Outdoor
<br /> Latitude { Q Closed Q Altered
<br /> Outdoor-
<br /> GPS Q Hauler Q Indoor
<br /> Q Inactive ( Truck
<br /> Longitude - Q Planned Q OTR Q End-Use Q Container
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<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 /f _
<br /> Part B - Inspection of waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> j V A HAULING AND MANIFEST REQUIREMENTS
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension
<br /> 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 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/CIWMB Enforcement
<br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q ria 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> Q In Compliance - No Violations ,:
<br /> Q Q Other: § AL
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<br /> Comments -" r
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<br /> Inspection Form Included:
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<br /> Comments Included: w n ref
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<br /> Q Business Rep's Signature Phone Number Inspector's Signature _ 'Ps
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<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: 1. i,;i A Mi
<br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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