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® WasteaTire S 1&y & Inspection ReportO
<br /> lnspection Report Number ,.State of Californi
<br /> ■
<br /> - Califom-iaIntegrated MB 181 Waste ew 04104)
<br /> Management Board Survey Form - Page .1 ; - 1 0_ I 13, $
<br /> Part A- Survey BLUE OR BLACK INK PEN
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<br /> TPID- _. - rij�� Inspection Type (Fill one)
<br /> Site Suffix:
<br /> J j Routine Q Re-inspection Q Referral Q Observation
<br /> LocalIf Referral,choose referral type(Fill one)
<br /> Identifier: ( l�L '(,4 ` vim..
<br /> t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address -
<br /> i
<br /> Street y--
<br /> r / Inspection Date
<br /> City State 7 ZIP Code Time In Time Out
<br /> Business Rep Title Q AM pr— Q AM
<br /> r O PM PM
<br /> Operational Status I k ,+ Business Rolei�1pe
<br /> r (Fill one only) (Fill all that apply)
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<br /> (J)Active FaS tr N l� r Q Generator
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<br /> G PJ Latitude LLL I I!
<br /> �� Q Closed l^ d! o-r«d Wr p rf!�� r ✓
<br /> � ,✓ ja ;✓! Q Hauler
<br /> O rrIt1c# rY
<br /> y « a"v
<br /> Q Inactive Q d� i� ✓� ✓, W«r
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<br /> Lon Longitude QPlT
<br /> UPlanned se
<br /> Q New Tire Dealer ® 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 /> 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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ---------
<br /> Q0
<br /> 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
<br /> ' In Comlience - No Violations
<br /> O Q Other: §
<br /> Comments
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<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:O, incorrect: ( 11' A p f
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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