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Inspection Report Number
<br /> Waste Tire �rey & Inspection Rep�-
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<br /> State California a
<br /> ca CIWMB 181(New 04/1 i 04) Survey Form - Page 1 . (u}
<br /> California Integrated Waste Management Board -
<br /> 10649 1
<br /> Part A- Survey _ yBLUE OR BLACK INK PEN
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<br /> TPID- j J C + C, Inspection Type (Fill one)
<br /> Site Suffix: ( I 1 Routine 0 Re-inspection 0 Referral Q Observation
<br /> Local I If Referral,choose referral type(Fill one)
<br /> Identifier: (� -t 11^TI R (�f r� ft,j`�-, "( O CHP O CIWMB Q Complaint 0 Educational Visit Q Other
<br /> - -- _ _
<br /> Business or Facility Name -
<br /> Inspected By Inspector
<br /> Physical Address -
<br /> Street
<br /> Inspection Date )
<br /> i
<br /> Citi State ZIP Code Time In Time Out r
<br /> Business Rep Title Q AM_I PM � AM
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<br /> I 'Operational Status �ar Business Role
<br /> (Fill one only)
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<br /> (Fill all that apply) , Ihli°tkitIY
<br /> r a l r a r F f�^� � er N
<br /> Active ( w;1snr ® Generator �QgYGkC11r"� s"°
<br /> G a ^ aaanr � r aaro'atal / rn ,dFr
<br /> �� — ClosedLatitudeGPS i� ® Hauler
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<br /> Longitude
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<br /> O Planned �"r7tre i ® End Use �9sr nu� rt >r
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<br /> 0New Tire Dealer Q Auto Repair Q Trucking Fleet0Government �0 Retreader� O Dismaa�ntler Q Tire
<br /> rF.Derived
<br /> ived Fuel
<br /> Y
<br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Crumb Rubber
<br /> O Service Station 0 Hauler 0 Agriculture O Shredder 0 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 0 Extension
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m FT]
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ------
<br /> 0
<br /> _ — - -_-O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> O O 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
<br /> Q Q Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: , }t M P 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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