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Waste Tire Su.. ^ Inspection Repor I ctlon Report Number ■
<br /> ` �' cwnne 811(New04/04) Survey Form - Page 1 fornia 1 i - $
<br /> California Integrated Waste Management Board
<br /> Part A- Survey BLUE eOR BLACK INK PEN
<br /> $+rM
<br /> '2 ,, r 11
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<br /> "TPIDInspection- Type (Fill one)
<br /> Site Suffix: - I.
<br /> -- � #Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: ( ttr� kA t o- t t=>, l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical AddressT F-d ......
<br /> Street
<br /> Inspection DateLL E
<br /> /
<br /> City State ZIP Code Time Out
<br /> Time In
<br /> j Business Rep Title OAM 0 AM
<br /> O PM [T-1 O PM
<br /> Operational Status Business Role
<br /> � r
<br /> (Fill one only) �tty, (Fill all that apply) y7" 11 � 1
<br />� ! � ` ✓ h% +°,+1 �E� i t°/a��`7 f/��5�� + ,aapr
<br /> Active 3 Generator
<br /> 0 Closed
<br /> Latitude 0 Hauler
<br /> 00 Inactive
<br /> a„a��E�l+`���1�«7 �E ,4 ✓�ti�(�`�" +d l�'�; t
<br /> ,� 7 ' xr��n�r o-u � End-Use
<br /> Longitude - 0 Planned ✓r1 � )( 0 ,u 't✓
<br /> y"".rrvll +z'+t.rna , ,�w mC,,aa^.N rrn i,M•'ila w 1 �J.s�'M.
<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking'rleet O'Govefrhrrtent 0 Retreader # 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 Agkculture 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 EQUIREMENTS
<br /> O 0 0 Notice Of Violation 0 Extension
<br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 Q 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
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> m: m
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days
<br /> (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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations
<br /> 0 0 Other: § _
<br /> Comments
<br /> u.J4�/�
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<br /> INSTRUCTIONS ON BACK Correct Incorrect: X a�'M p � � � � 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® S
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