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<br /> Waste Tire SuOey & Inspection Repor4 Inspection Report Number ■
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<br /> state of California -
<br /> CIWMB 181(New 04/04) Survey Form - Page 1 - Aa ifornia Integrated Waste Management Board _._ - _
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> f TPID- Inspection Inspection Type (Fill one)
<br /> Site Suffix:
<br /> Q Routine a:= Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected'! r p _By Inspector
<br /> Physical Address (r - ! t!,
<br /> 11
<br /> Street
<br /> Inspection Date
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<br /> City State ZIP Code Time In Time Out
<br /> Business Rep } /- d Titles AM m Q AM
<br /> /1,1 1� 1'"f�e/- " � v 0 PM 0 PM
<br /> 1111mill 111inill;1I Iii III Is —
<br /> t,r Operational Status ) `r Business Role
<br /> (Fill one only) t `�I"apt( ° (Fill all that apply)
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<br /> Planne " End Use �
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 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
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ; ENFORCEMENT STATUS
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<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsibles Complying r Manifesting Requirements Date
<br /> Q Q 14 CCR§18459.1 a)( )(c)-Tire Program ID Number from CIWMB
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT)
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<br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years --- --
<br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred(CIWMB Enforcement
<br /> Q 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
<br /> In Compllanc tFlo Violations
<br /> Q Q Other: §
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<br /> Comments j
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<br /> --- * � �/ E �4 A r L E 1 � � 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: � ��,: ��� �_��-��
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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