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Waste Tire Su*y & Inspection Repor
<br /> State of California inspection Report Number
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<br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 4 -,. 1 �.-,. 3
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<br /> California Integrated Waste Management Boa
<br /> PartyA Survey BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: ) ( - E,) (p`Routine QRe-inspection QReferral
<br /> Q Observation
<br /> Local
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<br /> Identifier: r QCHP QCIWMB QComplaint
<br /> QEducational Visit QOther
<br /> Business or Facility Name -
<br /> Inspected By Inspector
<br /> Physical Address
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<br /> Street
<br /> / r Inspection Date t
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<br /> City Time In_ Time Out
<br /> Mate ZIP Code
<br /> Business Rep Title
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<br /> Operational Status art r'��d " � � Business Role
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Government Retreader Dismantler
<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 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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Notice Of Violation Q Extension
<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 -Responsible Entities Complying in9 with Manifesting Requirements
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<br /> Date
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m
<br /> Q 014 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required'for NOV or EXT)'
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years — -
<br /> Q Q 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 Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect. 1 ` 3 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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