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Inspection Report Number
<br /> Waste Tire Sy & Inspection RepoT
<br /> State of California r
<br /> CIWMB181(New 04/04) Survey Form - Page 1 8 - 10 1 0 5 14 .I
<br /> California Integrated Waste Management Board
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<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> Site - 3 Inspection Type (Fill one)
<br /> Site Suffix: f„ (Z) Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local ( If Referral,choose referral type(Fill one)
<br /> Identifier: �CJ�t ii ,• .. r; t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> s or Facility Name
<br /> Business r Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep TitleLEQ AM Q AM -
<br /> , 'F�G:) Jt.1�/ 'tib •t.: t �
<br /> Operational Statusrf � ,h r�r Business Rolet
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<br /> (Fill one only) t� � � (Fill all that apply)
<br /> a
<br /> 3
<br /> At
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<br /> Q ActiveiWf3 � y ,g 'Generator
<br /> 0
<br /> 0 Closed � Hauler
<br /> �" �o rro �r r
<br /> Latitude
<br /> GPS Iw� m w
<br /> 0 Inactive � 4�r n � r1a�r
<br /> Longitude - * , r i r
<br /> 9 0 Planned gra rrtai 0 End-Use
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<br /> a.,. ,.. ... .. ,.
<br /> 0 New Tire Dealer @LAuto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 Used Tire Dealer 0 Auto Body r3A Car Dealer 0 Collection 0 Crumb Rubber
<br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS
<br /> p Y
<br /> V ' A ,I HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / W / m
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV'orEX7)
<br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement
<br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> 0 0 Other: § _
<br /> Commentsr I r -J
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<br /> 62081
<br /> INSTRUCTIONS ON BACK 'Correct: Incorrect: ; I I A 1t�"II P I 1 ,
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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