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ins ection Re ort Number
<br /> Waste Tire SuW & Inspection Report. p __._ p _ _ -
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<br /> StWMB ate B 181 New 04/04)California
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<br /> Survey Form - Page 1 1 2 . 10 1 0 5 44
<br /> California Integrated Waste Management Board " --- -- - - --
<br /> Part A- Sur, BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br />} Site Suffix: ) ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local _ �.' If Referral,choose referral type(Fill one)
<br /> Identifier: j ;1 s') )U 0, f:i to Y•, {. �j t v;L y Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
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<br /> Physical Address I ( ✓. i Mfr r'
<br /> Street
<br /> f Inspection Date
<br /> cityState[ State `ZIP Code Time In Time Out
<br /> Business Rep Title 0 AM 0 AM
<br /> ,.I = � — 0 P 0 P
<br /> Operational Status t{ r Business Role
<br /> (Fill one only) (Fill all that apply) Y,�I( pr��fpply
<br /> 'ly�lyr,�tr
<br /> ® Active ytQ � a� (3 Generator
<br /> 0 QCIOSed
<br /> gra Mw p ry t �,
<br /> IGPS
<br /> Latitude - r�&, 9 ,Yti re f I � ,tir va 4dw tl!�'; r+`✓ 7�,a'bra
<br /> 1rr" a)rr aN't Q Hauler I � ,
<br /> Qnacinactive
<br /> Longitude ' Q Planned {pr Q End Use
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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 ,1((t_A I/ '�f i'
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> 0 § Hauler
<br /> I9dTransport 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
<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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q in Compliance - No Violations
<br /> Q Q Other: § l
<br /> Comments No !i / 1/i(::41' f c�� j! IC.' � tjo 0' C".)os rtu
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<br /> INSTRUCTIONS ON BACK `Correct:* Incorrect: X 'h;, �/; A, 62081
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<br /> �° White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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