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<br /> A Spection Report Number
<br /> Waste Tire Su&y & Inspection Report _
<br /> State of California Jf j �J� 3 �j(
<br /> CIWMB181(New 04/04) Survey Form - Page 1 Y Y f L V
<br /> California Integrated Waste Management Board
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- — Inspection Type (Fill one)
<br />} Site Suffix: � � 1 L
<br /> :� :
<br /> Routine Q Re-inspection Q Referral Q Observation
<br /> - --- ——--
<br /> Local r y . If Referral,choose referral type(Fill one)
<br /> Identifier: CHP CIWMB Complaint Educational Visit Other
<br /> Business or Facility Name -
<br /> { _ Inspected By Inspector
<br /> i �' J n- ,',;� rV Ei
<br /> Phyl dH1 J
<br /> Street W C - p 1
<br /> �I Z_ , / 4_ Inspection Date
<br /> City State ZIP Code Time In Time Out __
<br /> Business Rep Title 0 AM
<br /> O PM . ��_ O PM
<br /> Operational Status r f Business Rope -Storage Type
<br /> (Fill one only) (Far�f r (Fill all that apply) (Fill all that apply),
<br /> �Tlre Count(1rVhole/I'TE) ar
<br /> Active ( f' (5 Generator 0 Outdoor
<br /> Q Closed
<br /> PS Latitude
<br /> Q Hauler Q indoor
<br /> Q Inactive Q Truck %in(l;.
<br /> o
<br /> Longitude Q Planned Q OTR Q End-Use Q Container
<br /> Business Type (Fill aft fha't apply)
<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 /> I
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS-
<br /> i
<br /> HAULING AND MANIFEST REQUIREMENTS II \/ A NTS-- — --_ 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> M / M / FT]
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q Q 14 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 P
<br /> Q In Compliance No Violations
<br /> Q Q Other:
<br /> Comments ' J
<br /> FIJrr
<br /> � .
<br /> __ —
<br /> Inspection Form Included: Cr
<br /> Comments Included: Q
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect:
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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