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<br /> Waste The 81: 011$ eCtlOn Re' Inspection Report Number
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<br /> � State of California � � _.... - ■
<br /> Ei33�9 CIWMB 181(New 04/04) Survey Form - Page 1 � � � � � � � � .� j �
<br /> California Inte rated Waste Mana ement Board -
<br /> Part A�Survey s BLUE OR BLACK INK PEN
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<br /> TPID- c � ,,, � (,, � Inspection Type (Fill one) �
<br /> Site Suffix: �l I r: � � r � i — � � Routine Re-ins ection
<br /> Q Q p Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier:
<br /> i _.__ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name � - - -
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<br /> Inspected By Inspector
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<br /> Physical Address 1 �� - � �, / - uti r
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<br /> Street
<br /> 1 _��� i� Cl Inspection Date /,? "� / �> � / �
<br /> Cify � State ZIP Code (Tim_e_In Time Out
<br /> Business Rep Title h �� • I �O PM �_"�_1_ -_..I • C_�� O AM
<br /> _ �J O PM
<br /> I -- — 1t P � m ��" Ar7�ry,r'"r s�,� � i �'a'fv l `"v9v
<br /> � Operational Status i�°�n � r� r ryn r Business Role
<br /> (Fill one only) � ����� ��� �(Fill all that apply) ��4 � I, .
<br /> 0,:'i"�� Q Active I(,� �a'��i� ,+ �� � Q Generator �a-�a ������ �"
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<br /> _ _ Q ¢�t4 ��r �r � u +r� Q Hauler i)x� � �.
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<br /> • � Q Planned ���, ���+� Q End Use ,� 4
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<br /> Q New Tire Dealer Q Auto Repair ;�� 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 Q Other
<br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility E_N__F_ORCEMENT STATUS I,
<br /> - ” - -" --
<br /> N � A �HAULING AND MANIFEST REQUIREMENTS
<br /> Q Q �PRC§42951 -Waste Tire Hauler Registration and Transport of Tires I
<br /> Q Notice Of Violation Q Extension
<br /> PRC§42953-Contracts with Re istered Waste Tire Haulers.
<br /> Q Q 9
<br /> Compliance Deadline. `
<br /> Q Q PRC§42956-Registration/Decal in Vehicle I
<br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements I]ate i
<br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m � m / 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)` I
<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
<br /> Q Q Other: § Q In Compliance - Na Violations
<br /> Comments r _
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<br /> INSTRUCTIONS ON BACK 'Correct: Incorrect: I i , � II �` 'i�( �,�”; �' I_�C � 1 t �� 62081 � <_�
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® t
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