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lnspection Report Number
<br /> Waste Tire Su y & Inspection Report
<br /> California� State B California :.
<br /> B- 1
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<br /> Part A- Survev BLUE OR BLACK INK PEN
<br /> spection.
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<br /> Inspection Type (Fill one)
<br /> Ste Suffix: / 1 --2'1 /7 i`� `� � �. ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local , If Referral,choose referral type(Fill one)
<br /> Identifier-- 14 t r z ;
<br /> G. C.r_.. Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name '
<br /> Inspected By Inspector
<br /> Physical Address C% Ld L/ 21�1 �_; ,� ;�k�J
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<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code Time In� Time Out
<br /> Business Rep Title 0 AM [:17 O AM
<br /> L�l ' �' � 0PM � -- 0P
<br /> i i Operational Status e r yp 5! Business Role " r .
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<br /> � (0 Active h>i + 'r e 1" �� ® Generator
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<br /> ® 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 ® 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 /> -_
<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 / FTI Q
<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 O - - -
<br /> 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
<br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> ,,Yv In Compliance - No Violations
<br /> Q Q Other: § _
<br /> Comments
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<br /> INSTRUCTIONS ON BACK j Correct:
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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