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Waste Tire Su�y & Inspection Report Report Number ■
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<br /> State of California
<br /> Baa CIWMB 181(New 04/04) Survey Form - Page 1 0 1 0 6 l 6
<br /> California Integrated Waste Management Board
<br /> Part A- Sursv�e BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br />} Site Suffix: t {I / ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local
<br /> If Referral,choose referral type(Fill one)
<br /> Identifier: J f
<br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name 1, -
<br /> 'Inspected By Inspector
<br /> Physical Address l
<br /> vl
<br /> Street
<br /> • g , Inspection Date
<br /> 7
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title 0 AM 0 AM
<br /> �/. 0 P � � 0PM
<br /> I l�iU.) , •: 4 l��frt tit r �.. -
<br /> �,,w«r ,�^ ,rN,a,rrr ,rc.���„Operational Status , �`` � Business Role
<br /> (Fill one only) t (Fill all that apply)
<br /> Active Generator
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<br /> Q Inactive 0 Q Closed
<br /> GPS Latitude Q Hauler
<br /> D � °��rr
<br /> �c
<br /> Longitude — t Q End-Use
<br /> Q
<br /> Planned °Ct V r a la
<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 Other i �,UriA 0T_av
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V 1 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 /> I
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> M
<br /> 0 Q14 CCR§18459.1 a (b) c -Tire Program ID Number from CIWMB
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<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days
<br /> (Required for NOV or EXT) r Nt�fM;t x;
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<br /> QQ 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')
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<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 r”
<br /> In Compliance �
<br /> Q Q Other: § f 'tf�
<br /> Comments ,
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<br /> INSTRUCTIONS ON BACK Correct: R Incorrect: ' ) _^; I A , ( _..�.. L 62081
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