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<br /> Waste Tire S & Inspection Repo- pection Report
<br /> . (California
<br /> CIWMB 181(N
<br /> .:�1, CIWMB 04/04) Survey Form - Page 1 � � - � � � 3 � 4 �
<br /> California Integrated Waste Management Board - _. ... .... .i
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> TPID- - r Inspection Type (Fill one)
<br /> Site Suffix: Q Routine Q Re-inspection Q Referral Q Observation
<br /> Local , If Referral,choose referral type(Fill one)
<br /> Identifier:
<br /> CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name I Inspected By Inspector
<br /> Physical Address ( � j IT ;
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title0 AM 0 AM
<br /> I y(� y, 1 t r" k- Lf= ), �\ (�PM M : EII 0 PM
<br /> Operational Status / a ar /� Business Roler �' t
<br /> � (Fill one only) i SIIie (Fill all that apply)
<br /> '•,.i
<br /> Q Active �Q; tetr' Q GeneratorILL .1
<br /> Mqw
<br /> GPQ Closed
<br /> S Latitude 1Q Hauler
<br /> Q Inactive
<br /> 'rv'
<br /> w yd+rr=a:
<br /> Longitude anne0 End-Use
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<br /> 0 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
<br /> 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 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> /
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date
<br /> 00 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB M71 / m
<br /> p
<br /> (Re uired for NOV or EXT)
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days ,
<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 /> 1
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q (D 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 23 In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: A ; r
<br /> 8 � 8 ^ i�' ( r .i 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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