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In3pection Report Number
<br /> Waste Tire Suf & Inspection Re or
<br /> State California Survey Form - Page 1
<br /> CIWMBB 181(New 04104)
<br /> California Integrated Waste Management Board ---- ------- - -- -
<br /> Part A- SurveyBLUE OR BLACK INK PEN
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<br /> TPID- �` --- JA - �-__—L ``1 Inspection Type (Fill one)
<br /> Ite Suffix
<br /> L
<br /> (j&Routine 0 Re inspection Referral 0 Observation
<br /> o -- - — —_
<br /> 41-
<br /> Local 1. If Referral,choose referral type(Fill one)
<br /> Identifier: - 7
<br /> 0 CHP 0 CIWMB 0 Complaint 0,Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> IPh sicalll dres” OT
<br /> Street
<br /> Inspection DateRH
<br /> I t I Time In Time Out
<br /> City State ZIP Code
<br /> Business Rep Title 0AM 0 AM
<br /> 1 1)
<br /> ETI : 0 PM 11-1 : 0 P
<br /> Operational Status Business Role
<br /> (Fill one only) !(Ld�� Yf t ( ` (Fill all that apply) W( m�lfnli a Vii'
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<br /> T:Active et1 Generator
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<br /> O 0 Closed ( ( d r
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<br /> Latitude
<br /> GPS --- Inactive 0 nt 0 Hauler rNy
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<br /> Longitude
<br /> wi End-Use
<br /> 0 Planned
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<br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber
<br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other
<br /> i
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A ,,HAULING AND MANIFESTREQUIREMENTS
<br /> O 0 0 Notice Of Violation 0 Extension
<br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / /
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 0 m m
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> 0 0 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 0 Referred f CIWMB Enforcement
<br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _ -
<br /> 0 ' 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments >
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<br /> / 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �,
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA S
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