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Waste Tire Sulty & Inspection Repor Inspection Report Number_
<br /> •�"`�® � State of California - -- ■
<br /> CIWMB grated 1st(New Manage Survey Form - Page 1 L -_ 1_0_ 6 3 9 3 "
<br /> California Integrated Waste Management Board ,__, _ _ __
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> T_PID- ! .� i �`- C! ! - �_--- - Inspection Type (Fill one)
<br /> Site Suffix:
<br /> +— ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Fi Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected B
<br /> p y Inspector
<br /> (;_ ( �`
<br /> I J
<br /> Physical Address r✓ l {� - %r.t i;; L •4
<br /> rv.�'J
<br /> Street
<br /> r_ Inspection Date / l• ? /
<br /> City State ZlP Code Time In Time Out
<br /> Business Rep Title Q AMn AM
<br /> I 11 1 ( PM ___:
<br /> IL
<br /> � ! { or PM
<br /> -„ Operational Status M , , �,,r, Business Role
<br /> (Fill one only) i " 'i (Fill all that apply)
<br /> !
<br /> Active Generator
<br /> loom[,
<br /> a r' rw r ria t
<br /> O OClosedLatitudeGPS
<br /> Q Hauler ) tr
<br /> Q Inactive �Y Tntk 1rsr
<br /> d u : M rrrfaY rar Z✓ a�t"fir�n y✓g �tjHll
<br /> Longitude S,: � rw a v tura
<br /> Q �dnfatKl (a
<br /> - Planned �""r /taw��i�"r�' "� End-Use
<br /> O Pld "!wl, nyw
<br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ®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 Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFESTRRQUREMENTS O Notice Of Violation Q ExtensionO O § eHauIRegistration
<br /> dTransport 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 /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> Q O 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 /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> Q 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
<br /> Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments � r
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<br /> INSTRUCTIONS ON BACK
<br /> Correct:i Incorrect: '�. �A MTI
<br /> FE 1 21.31 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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