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<br /> Waste Tireey & Inspection Re m
<br /> Inspection Report Nuber
<br /> fliID � State of California
<br /> CIWMB181(New 04104) Survey Form - Page 1 1 ' 10
<br /> 2 5 - 12
<br /> Part A SurveyBLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: %�? -%T/� - ] - ' / (D Routine 0 Re-inspection 0 Referral 0 Observation -
<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
<br /> Inspected By Inspector
<br /> Physical Address -i 1j f c .1, /
<br /> Street
<br /> c Inspection Date
<br /> OL
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<br /> City State ZIP Code Time InTime Out _
<br /> Business Rep Title . ��O
<br /> _—_ __ - - AM OAM
<br /> PM � �❑ 0 PM
<br /> Operational Status taJr� +" Business Role
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<br /> Active erl %rw 0 Generator
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<br /> 0 Closed
<br /> GPS Latitude m .
<br /> 0 Hauler L r
<br /> xis t >r� d u�F.Ja rr: a u� 9 a✓�'�.
<br /> 0 Inactive
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<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet Q Government 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 0 Agriculture 0 Shredder 0 Other 1 '/�A i
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A PRC 42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension
<br /> HAULING AND MANIFEST REQUIREMENTS
<br /> 0 O § g p
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 1 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 0
<br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m
<br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> 0 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 /> 0 I 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: ( A 1A,P I E + � � � �; 62081
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<br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA
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