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Waste Tire S & Ins ection Re or Inspection Report Number
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<br /> .fir is State dCalifornia Survey Form Page 1 - Q $
<br /> CIWMB 181(New 04/04)
<br /> California Integrated Waste Management Board
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> ,. 40
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<br /> TPID- I I - EE-
<br /> Inspection Type (Fill one)
<br /> Site Suffix 2
<br /> 9Routine Q Re-inspection Q Referral Q Observation
<br /> Local - f) If Referral,choose referral type(Fill one)
<br /> Identifier: c 1
<br /> .,.I C=-f t t t v t L U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name - -- - -- --
<br /> Inspected By Inspector
<br /> Physical Address-----
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<br /> Street I {=0 ,c—
<br /> �- / 2 Inspection Date ( C)cc-( uY / / V
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<br /> City State ZIP Code Time In Time Out _
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<br /> Business Rep Title ' ��0 AMO PM0 AM
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<br /> r ¢ Operational Status 4T ( Business Roler�
<br /> (Fill one only) ( 4" I, �� t� (Fill all that apply) tO '
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<br /> ® Active �, (5 Generator
<br /> O Q Closed
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<br /> G PJB' Latitude �y "�r✓t r 4y `�„+ %w >vz Q Hauler
<br /> Q Inactive
<br /> Longitude - QPlanned fart Q End-Use
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<br /> Q New Tire Dealer 9 Auto Repair Q Trucking Fleet Q Government Q Ret„reader 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
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<br /> Part - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
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<br /> VV A HAULING AND MANIFESTREQUIREMENTS Q Notice Of Violation Q Extension ral
<br /> Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadllne
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date'
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m
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<br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days "' (Requiredfor NOV or EXT) -
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
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<br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred,r CI+II1 MB' Enforcer nt
<br /> O 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 WIn Compliance No Yialations
<br /> Q Q Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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