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Waste Tire Sur6y & inspection Report Onspection Report Number ■
<br /> State of California
<br /> ®®i.A CIWMB 181 New 04/04) Survey Form - P a e 1
<br /> California Integrated Waste Management Board J -
<br /> Part A- Survey BLUE ORB-LACK INK PEN
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<br /> TPID- _
<br /> Inspection Type (Fill one)
<br /> Site Suffix: QRoutine Q Re-inspection
<br /> ection Q Observation,
<br /> Local ,� — If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name I Inspected By Inspector
<br /> Physical Address E/I
<br /> 5
<br /> Street
<br /> Inspection Date1 (�
<br /> r j
<br /> Time Out
<br /> City State ZIP Code Time In_ _
<br /> Business Rep Title ff DAM [=
<br /> L-H � AM
<br /> 0PM 0 P
<br /> Operational Status ,fir �, ��i Business Role ',
<br /> (Fill one only) (Fill(Fill all that apply)
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<br /> r
<br /> Q Active 5� wfr Q Generator ;
<br /> 0 ®
<br /> Closed
<br /> PSLatitudeCal�G�ra tf�k�(rt)ata/mrri Q Hauler
<br /> Q inactive
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<br /> ogituQ End de Q Planned
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<br /> Q 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 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q 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 Q Referred J CIWMB Enforcement
<br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities ------- _ _
<br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> 0 0 Other: § -- -
<br /> Comments
<br /> 51
<br /> 771
<br /> Inspection Form Included: Q',
<br /> Comments Included: 0 _
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:� Incorrect: 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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