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Waste Tire Su & Inspection ReporiWpection Report Number
<br /> _ . __-
<br /> Sa-" State of California
<br /> CIWMB 181(New 04/04) Survey Form - Page 1 8 D 13 5 3 6
<br /> California Integrated Waste Management Board
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> �c✓ lcdi✓Ma v/ 7 rla� -. d
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<br /> l TPID- Inspection Type (Fill one)
<br /> Site Suffix: oC - l
<br /> - - `' 0 Routine 0 Re-inspection 0 Referral Q'Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 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 /> J'
<br /> Inspection Date
<br /> State Zip Code Time In Time Out�,
<br /> Business Rep Title AM / AM
<br /> R > -- _ _ O PM ' f I1, 0 PM
<br /> 1 z! -,
<br /> mai ,'✓ �; Operational Status Business Role
<br /> (Fill one only) �{ � (Fill all that apply) s
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<br /> IF
<br /> 12?
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<br /> 7 ,�,....:M✓ l o-tr i �r., ✓,'. err:* , rear^ ACtIVe ✓ �'�:. Qi Generatora`4
<br /> O / m, fir/ ✓ �, r �a n ��
<br /> Latitude Closed
<br /> GPS - LL L-L I 1h r (5 Hauler t) cf
<br /> Inactive
<br /> � M Tk c, ('���fir '�1 a f!'a�/,'r ��S ✓ yn'e q
<br /> Longitude - 0 Planned f /i>a✓( End Use �� " +r017itir* r'
<br /> Bus`irte5s Ty�fe (,
<br /> 0 New Tire Dealer 0 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 /> Q Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other t
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V I A HAULING AND MANIFEST REQUIREMENTS
<br /> ----- -- -- 0 Notice Of Violation 0 Extension
<br /> 0 Q 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 Date M / M / m
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<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 11 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 /> Q, 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
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect r I w ( l L 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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