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Waste Tire Suy & Inspection Reportlnspection Report Number-pll
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<br /> Sate ofCaliforniaI CIWMB 181(New 04104) Survey Form - Page 1 - _�- 3
<br /> California Integrated Waste Management Board
<br /> Part A Surve BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
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<br /> Site Suffix: L� I 4 Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: �! �,. �� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical AddressU-7-
<br /> / Inspection Date
<br /> State ZIP Code Time In Time Out
<br /> Business Rep Title m O AM m m 0 AM
<br /> (i' I�L 0 PM IBJ - 0 PM
<br /> Operational Statusr (� r Business Role
<br /> (Fill one only) �� (Fill all that apply) 'rb
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<br /> 0 Q Closed �"' ��' � �Latitude , Q Hauler
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<br /> Q Inactive .�' ,�•�
<br /> Longitude - 0 Q Planned Q End Use
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<br /> Q New Tire Dealer Q Auto Repair 0 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 ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements DateQ Q
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<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 (a 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators IQ In Compliance - No Violations
<br /> O O Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: V; j - , �' L t 62081
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