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Waste Tire Sy 8c Inspection Repo -Inspection Report Number
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<br /> State of California -
<br /> L CIWMB 181(New 04/04) jJ
<br /> California Integrated Waste Management Board Survey Form Page 1 1
<br /> Part A
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<br /> BLUEOR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix:
<br /> -IRoutine Re-inspection ection Referral Observation
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<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 Inspected By Inspector
<br /> Physical Address I t i _L—_I T
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<br /> Street
<br /> Inspection Date
<br /> ty State ZIP Code Time In Time Out
<br /> iness Rep Title _ Q AM O AM
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<br /> ' Q PM h`, _� C- @ PM
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<br /> Operational Status M Business Role
<br /> o% (Fill one only) (Fill all that apply) 1a�1�(� 1'
<br /> ® Active Q Generator
<br /> [7]0 Closed
<br /> PSLatitudeG
<br /> l,""tr✓ �"'ar' �� rrpy(w1, � auler
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<br /> # J✓ a�M+ '� ri/r y i^'�
<br /> 0 Inactive10
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<br /> Longitude — 0 Planned "s /� Ii� End Use
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<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0Government 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 Q Agriculture 0 Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
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<br /> A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 li 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
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<br /> 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 14 CCR 18459.1 a)(b)(c)-Tire Program ID Number from CIWMB m m m
<br /> § ( (Required for NOV or EXT);
<br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days
<br /> 0 0 1 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 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Manifest System Requirements for Tire Dealers or Waste Tire Generators —
<br /> 0 � 14 CCR§ 18462- (� In Compliance - No'Viol ations
<br /> 0 0 Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:4 Incorrect: PME1 1117620811
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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