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<br /> Report Number
<br /> Waste Tire Sutby & Inspection Reports Inspection ■
<br /> State of California
<br /> CIWMB181(New 04/04) Survey Form - Page 1 $ - '� 3
<br /> California Integrated-Waste Management Board -- -- - - - --
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> ss Profile Inspection Details
<br /> TPID- ) 7 Inspection Type (Fill one)
<br /> Site Suffix: / j / Routine Q Re-inspection (D Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: E,00, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> I
<br /> Physical Address EE11
<br /> I
<br /> Street
<br /> _ .., Inspection Date
<br /> Jr'� State LIF'Code Time In_..._... �! Time Out }
<br /> City _
<br /> Business Rep Title 0 AM
<br /> 0 PM Ej] :
<br /> 0 AM O PM
<br /> Operational Status Tire Type Business Role Storage Type
<br /> (Fill one only) ,(Fill all that apply) (Fill all that apply) (Fill all that apply)
<br /> � The Count(1�lhole/PTE) , �
<br /> > Q Active Q Passenger Q Generator Q Outdoor
<br /> ® Closed Q Altered Q Q
<br /> Latitude "�� Indoor
<br /> --� 0 Q Inactive Q Truck Hauler
<br /> Longitude ! Q Planned Q OTR Q End Use Q Container
<br /> _J_
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<br /> Q 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
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A I 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> aQ 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Y w.
<br /> Comments
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<br /> Inspection Form InClUded QI..�•;;. „'. . i7", } r ",+,.ti's: r> r,ryt.,,,. s^ a ,r4k at� h` rr '�<� w rsr � 1'•r'tf �r�ao,� Na i+ fi� i'" y �r.r
<br /> Comments Included: Q
<br /> Business Rep's Signature Phone.Number
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �A, 2�31 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ��
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