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<br /> Waste Tire Su- & Inspection Re ort Inspection Report Number
<br /> u.�.W „/ ------
<br /> ��$ � State of California Y � � �— ---------- /'�
<br /> C,WMB 181
<br /> ew 04/04)
<br /> California Integrated WastJe Management Board Survey Form - Page 1 j_'� - .' 10 0 8 0 1 6 -:
<br /> Part ASurvey
<br /> 5� rvt .. t, , BLUE OR BLACK INK PEN
<br /> TPID-
<br /> Inspection p Type (Fill one)
<br /> Routine 0 Re-inspection Q Referral Q Observation
<br /> Local
<br /> Identifier: If Referral,choose referral type(Fill one)
<br /> ------� Q CHP Q CIWMB 0 Complaint Q Educational VisitOther
<br /> Business or Facility Name — — O-
<br /> Inspected By Inspector
<br /> Y t y
<br /> Physical Address j t
<br /> �
<br /> L;
<br /> � 4 [
<br /> Street =fi%` --T'
<br /> E7, Inspection Date
<br /> k fr f
<br /> City State ZIP Cone Time In Time Out
<br /> Business Rep Title Q AM Q AM
<br /> Q PM • QPM
<br /> rJ aux,
<br /> Operational Status x� r 'fr
<br /> ail p �' ���� Ma, Business Role
<br /> I1 (Fill one only) ' (Fill all that apply)
<br /> Irf 7 a ebwd a”i
<br /> ( Q Active Generator rr
<br /> ti' trM �
<br /> � rff 9rr "l
<br /> GPS Latitude � Closed
<br /> 100
<br /> as
<br /> Q Inactive �
<br /> '� O Hauler
<br /> Longitude _ � or,�rl nra+� r1at
<br /> a
<br /> rEnd-Usear�M�r
<br /> Q Planned F `" � �
<br /> OMANram, � a
<br /> l
<br /> New Tire Dealer Q Auto Repair 0 Trucking Fleet O Government 0 Retreader 0 Dismantler
<br /> Q Tire Derived Fuel
<br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber
<br /> O Service Station O Hauler 0 Agriculture Q Shredder O Other
<br /> I
<br /> winiPart B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityRM: i'
<br /> V 1 A HAULING AND MANIFEST`REQUIREMENTS -
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation (� Extension
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Desi'Brie "'
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> O Q 14 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 for NOV or EXT)
<br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers
<br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> Q 0 Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* incorrect: r j
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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