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Inspection Report Number ■
<br /> ,_ Waste Tire Suy & Inspection Repor0-
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<br /> ''^' ateof C4ltforma � ' I
<br /> HHHHSL CIWM61�f(New04/o4) Survey Form - Page 1 1 0 2 4
<br /> california Integrated Waste Management Board1 1
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- _ �L/� '7 l j Inspection Type (Fill one)
<br /> Site Suffix: Q Routine Q Re inspection Q Referral Q Observation
<br /> Local - ��� �� � �u )�{yL / — IfQReferral,chQoose referral tQype(Filpl one) Q Q
<br /> Identifier: ;% Yi r t CHP CIWMB Com laint Educational Visit Other
<br /> i Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address
<br /> Street 1 Inspection Date
<br /> i q�,) � � I Time In Time Out I
<br /> Ci(v State ZIP Code
<br /> Title � � AM 0 AM
<br /> Business Rep
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<br /> Operational Status t +r Business Role a r
<br /> �� m �rg�w�rrr"
<br /> (Fill one only) f1 1 (Fill all that apply)
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<br /> (V Active � H�� r (0 Generator Q Ct �Y✓
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<br /> O ( rr r;lrj r^nr�uz arm�w,'"rr�0�1 i��.�1m�+r�urdtY��,"ra�rytv'v
<br /> QClosed
<br /> Latitude Q Hauler
<br /> Q Inactive �for�yrl,r �vr,oX�tii ayT/a'rai ra
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<br /> O Q End-UseLon
<br /> Longitude Planned Q'OTR Corrtatner
<br /> Bu„-,sir�ess Type "f -
<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 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
<br /> Q Notice Of Violation Q Extension
<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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> M
<br /> / M / FTI !
<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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Gamphance No Violations
<br /> Q Q Other: § .__ R'" � rz �( t£rr� �,;
<br /> Comments -
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<br /> INSTRUCTIONS ON BACK Correct:* incorrect �,. a JJW"", L _ 1 _ !_ 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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