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Waste Tire SL*ey & Inspection Repors Inspection Report Number ■
<br /> State of California
<br /> CIWMB 181( e ) Survey Form - Page 1 _i 3 - 1 0 1 0 6 3
<br /> California Integrated WasttManagement
<br /> Waste Management Board -- l
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- f� Inspection Type (Fill one)
<br /> Site Suffix: ( I -r l i 3 Gr ��� — D Q Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: � �.� Uri •:r1{, 1 itl (�C i" 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name t : Inspected By Inspector
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<br /> Physical Address i) ? �� LL-i , `
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<br /> Street
<br /> Inspection Date
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<br /> city State ZIP Code
<br /> Business Rep Title E : [ T]OAM 0 AM
<br /> t j _ O PM 0 PM
<br /> �r Operational Status Business Role
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<br /> (Fill one only) (Fill all that apply)
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<br /> 0 Inactive
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<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 Used Tire Dealer 0 Auto Body 0 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 ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
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<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension
<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 / M / 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 or EXT)
<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 0 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 0 In Compliance - No Violations
<br /> 0 0 Other: § ------ _
<br /> Comments rro s )��C7��; c ) (:
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<br /> Inspection Form Included: 0
<br /> Comments Included: 0
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> _.. - • _ 6208.1._
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X :: , I
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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