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® Waste Tire Sl&y & Inspection Repor Inspection Report Number
<br /> State of California
<br /> CIWMB181(NewSurvey Form - Page 1 J..__._: _ - �. 0 0 0 4 3 0
<br /> California Integrated Waste Management Board
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> cyc r�
<br /> Inspection Type (Fill one) .
<br /> Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected B
<br /> p y Inspector
<br /> Physical Address
<br /> Street J
<br /> Inspection Date } / ' / [J�j
<br /> State Zip Code
<br /> Time In Time Out
<br /> Business Rep Title Q AM
<br /> / / r (D PM AM Q PM
<br /> Operational Status r /rd„ Business Role Storage Type
<br /> �1 � (Fill one only) � 1 d ��r (Fill all that apply)Y) (Fill all that apply)
<br /> �'�
<br /> / (D Active �� � Air @ Generator 0 Outdoor
<br /> O
<br /> GPS Latitude TF] 0 Closed
<br /> 0 Hauler 0 Indoor
<br /> �O 0 inactive
<br /> Longitude — a' ac 0 End-Use 0 Container
<br /> 0 Planned try r
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<br /> 0 New Tire Dealer D Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> Q 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V ! A !HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements DateB mm m / m W
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWM
<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/CIWMB Enforcement
<br /> 0 i 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 0 In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments
<br /> l�Cc 1 �� r - / /'c.L,/, r 1 tr o+ C.✓t _ / , - �T- i�1` U'j_.ter'' (/.. /�. �i i C
<br /> Inspection Form Included: 0
<br /> Comments Included: 0: -
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:• incorrect: X i A;Mj Pi 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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