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■ pection Report Number
<br /> Waste Tire SuSy & Inspection Repor ■
<br /> State of California nsiR
<br /> CIW
<br /> MB 181(New 04/04) Survey Form - Page 1 1 0 2 5 8 4 7
<br /> California Integrated Waste Management Board - --- ---- - - ---
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> TPID- ag � Inspection Type (Fill one)
<br /> Site Suffix: ? `� �+ i �1 (� ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local _ If Referral,choose referral type(Fill one)
<br /> Identifier: ,•t -t ti t;. s 1 l 0 U Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name t
<br /> Inspected By Inspector
<br /> Physical Address
<br /> ELI ' v 111
<br /> {
<br /> Street y
<br /> _ Inspection Date
<br /> Ct QJ
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep 1 , � Title LE 0 AM 0 AM
<br /> 0 PM 0 PM
<br /> Operational Status edj Business Role S
<br /> (Fill one only) �I)+ �4 r � (Fill all that apply) )r � ❑❑ )
<br /> »1 ,17 "n bs i 4ryYw
<br /> ® (S
<br /> Active � �, n '� Generator
<br /> _ �0
<br /> Q Closed " rYf'd �i� rt�r �r
<br /> Latitude _ 4�Z 1�� 1/at1 n✓q
<br /> Q Hauler
<br /> GPS
<br /> Q Inactive
<br /> Longitude — Q Planned { ) / O End Use
<br /> . p
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<br /> r
<br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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
<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 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> O O
<br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m
<br /> Re uired for NOV or EXT
<br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days p )
<br /> Q Q 14 aCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> i
<br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred t CIWMB Enforcement
<br /> O O 14 CCR§18401 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Gamplfance Na Violations
<br /> rr r;
<br /> Other: § �k�' �,_ rw)t( �iitY
<br /> Comments
<br /> (H
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<br /> ti¢1't'►rlletltS .ltlClud .
<br /> Bustnessp` ; It�atre;
<br /> -- 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect:
<br /> ® ---- -.
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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