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Waste Tire Sur * & Inspection Report Ospection Report Number ■
<br /> State of California
<br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 3 - 1 0 3 3 2 5 ^
<br /> California Integrated Waste Management Board
<br /> Part A Surve BLUE OR BLACK INK PEN
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<br /> Inspection Type (Fill one)
<br /> Site Suffix: t _� ���� Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: f t./ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> L—� 1, l j•r,- ._..� �.ti� � G', .� � � � � / � / �� 1� 7
<br /> Physical Address
<br /> Street �
<br /> Inspection Date
<br /> Tlme In Time Out
<br /> City State ZIP Code _._.--- —
<br /> Business Rep Title �� 1 �J C PM , 0 PM
<br /> w%Ir Operational Status Business Role
<br /> (Fillone only) (Fill all that apply)
<br /> Q �r �► ��p1
<br /> a� ro� ,r1rs r,t,
<br /> Active Q Generator
<br /> � Closed
<br /> GPS LatitudeFU
<br /> Q Hauler
<br /> Q Inactive ui )tXl ��w y�rrvra
<br /> Longitude — Q Planned Q End Use
<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel
<br /> 10 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 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle ii
<br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FT]
<br /> =m [—F]
<br /> O O
<br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWMB
<br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> - - - — —
<br /> Q 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 O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators i In Compliance - No Violations
<br /> O O Other: § -
<br /> Comments :^<
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<br /> 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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