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Waste Tire Su & Inspection Report+ Spection Report Number ■
<br /> :. -- _ _.
<br /> 1�77W: State of California
<br /> Cgrated Waste
<br /> eManag) Surve`, Form - Page 1 - $ U
<br /> California Integrated Waste Management Board ) _ n i
<br /> Part A Survey _ BLUE OR BLACK INK PEN
<br /> jg "gag
<br /> ,37
<br /> I TPID- Inspection T (Fill one)
<br /> („ 1 Site Suffix: ? ? ® Routine Q Re inspection 0 Referral Q Observation
<br /> i4 -
<br /> _- Local
<br /> If Referral,choose referral type(Fill one)
<br /> Identifier: O CHP O CIWMB O Complaint 0 Educational Visit O Other
<br /> Business or Facility Name Ins ected B
<br /> p y Inspector
<br /> Physical Address �
<br /> Street
<br /> _ Inspection Date
<br /> City _ State ZIP Code Time In Time Out
<br /> Business Rep Title ®PM (0 AM
<br /> D PM
<br /> Operational Status ,u Business Role `
<br /> (Fill one only) ill all that apply)
<br /> r�', v r ._ � s, .. ,•;,� ! "'raf6r*�,'� r
<br /> ® Activehs��P/ N Generator
<br /> Q
<br /> GPS Latitude �.�.� Closed t �! nr 'rtYµ C rYnr X y v
<br /> fna kr rt n O Hauler Cin u r
<br /> 0 0 Inactive xaYYr rN I lr C n
<br /> �*��'��,"��✓d r' "�,��)trM1 1 VwG f r"�rrE���r��q� w �a/1n,.
<br /> Longitude -
<br /> 0 Planned e' �
<br /> ��t� "MAX End Use Y,� ��fl
<br /> kr,
<br /> Q New Tire Dealer @) Auto Repair O Trucking Fleet Q Government O Retreader O Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer Q Auto Body Q Car Dealer O Collection O Crumb Rubber
<br /> O Service Station Q Hauler Q Agriculture Q Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
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<br /> V i A HAULING AND MANIFEST REQUIREMENTS
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Notice Of Violation Q Extension
<br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q O PRC§42956-Registration/Decal in Vehicle
<br /> QO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> [T]
<br /> O O14 CCR§ 18459.1 Oa Ob Oc Tire Program ID Number from CIWMB
<br /> 0 Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requiredfor NOVorEXT)
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<br /> Q 0 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 /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations
<br /> O Q Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �) 62081
<br /> White Copy:CIWMB Yellow Copy:Operator + Pink Copy:LEA
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