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Waste Tire Sur Y p��& Inspection Re orto' Inspection Report Number
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<br /> State of California
<br /> �➢ II
<br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 . 9 - 10 13 7 4 3
<br /> California Integrated Waste Management Board
<br /> Part ASurvey BLUE OR BLACK INK PEN
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<br /> TPID- s , + Inspection Type (Fill one)
<br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: t? ��r^ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name f /1 _ Inspected By Inspector
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<br /> Physical �4ddress _J
<br /> Street
<br /> T Inspection Date 's fes.
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<br /> f --- J Time In Time Out
<br /> City State ZIP Code EEo
<br /> Business Rep Title Ec;IoJ
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<br /> Operational Status f pfer Business Role
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<br /> . (Fill one only) fIJ+SIIt ( I (Fill all that apply) i 1
<br /> Active �r{�rS$ �(�rr ® Generator
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<br /> GPJ Q Closed
<br /> Latitude
<br /> x+r r.rnw1, Q Hauler
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<br /> Longitude — Q Planned rxr �/r"rtrri Q End Use
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<br /> Q New Tire Dealer (3) 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 /> Service Station Q Hauler Q Agriculture Q Shredder Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension
<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 Q m; / m
<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 In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> v 62081
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ; ~"
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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