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<br /> TWas,teaTire S*ey & Inspection Repor ction ort Number
<br /> p _-
<br /> State of
<br /> Ca p IWMB181(New04/04) Survey Form - Pa e 1 _3 - 1 0 0 6 5 2 1 ;;
<br /> California Integrated Waste Management Board J — -- -- ---- ---
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> -
<br /> �*�r
<br /> � ustt� aspect ota M�eta��e
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: S (U Routine Q Re inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: E_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code Time In _� Time Out
<br /> Business Rep Title , 0 PM LL LLI 0 PM
<br /> 115, Operational Status # z r Business Role cf+ r//;Yr
<br /> (Fill all that apply) �d� C
<br /> (Fill one only)
<br /> t Y
<br /> Active t )y Q Generator
<br /> D Q Closed
<br /> Latitude t it Y4
<br /> C7P5 t ��t �� Q Hauler
<br /> Q Inactive
<br /> o
<br /> Longitude – Q Planned Q End Use �frt
<br /> :'M ,^.�r, ,'*�
<br /> v w
<br /> ,.:..,
<br /> ��4'30
<br /> rlyt f.�� ��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 t `,A
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder QOther \� ? ` }
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS Q Q
<br /> Notice Of Violation Extension
<br /> Q Q
<br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953 Contracts with Registered Waste Tire Haulers. _Com liance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date / m / m
<br /> 14 CCR 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m
<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
<br /> I
<br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years t
<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 Q In Compliance - No Violations
<br /> Q O
<br /> Other:
<br /> Comments
<br /> -
<br /> s
<br /> a.
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<br /> — -- 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect X F + M.
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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