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<br /> Waste Tire Suy & Inspection Reportnspectlon Report Number
<br /> E re X333 w State of California I'4
<br /> $ate CIWMB181
<br /> Waste
<br /> eManag) Survey Form - Page 1 1 a - 1 0 1 3 2 5 3
<br /> California Integrated Waste Management Board --- -- --- -- — -
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> BU6CIti fiS11� 2 IoI: NI
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: ✓ �� J G :q,,Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: e, �t{ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> t Inspected By Inspector
<br /> Physical Address
<br /> ` f t� � Y{:.t•� it �•!.�
<br /> Street
<br /> Inspection Date
<br /> r 1`� ,.l ' Time In Time Out
<br /> city
<br /> ___ State ZIP Code ---__--
<br /> Business Rep Title O AM O AM
<br /> • :, i OPM m � � QPM
<br /> Osr erational Status p , �� i: Business Role
<br /> (Fill one only) tillt1 li
<br /> i) (Fill all that apply) uiIrCgm)
<br /> .i a V +'y,;.�a ¢w„ .., lY,,.'' '--i r” �� ,�,��+f< 7✓�n�r �r ✓u"� '�+�"". �S�.k�.; rk�rr i�
<br /> (DActive �^v ���� 0 Generator �mr �.J' ('�0',
<br /> 0 0 Closedn�" " �� 4d n : �� � 4° ✓�4 ' v
<br /> Latitude _ "to I,wfv< parr a" /i
<br /> GPS d r t �✓fii
<br /> � 0 Hauler
<br /> 0I n active eta t � GG r3 ( r r r�frr, ra
<br /> p t ass Gr: 16 1� r
<br /> �;y ��'K�9rvr, n✓ �t # H rr w r'v v er.
<br /> Longitude — 0 PlannedY� ` ,
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<br /> 0 New Tire Dealer 0 Auto Repair (3 Trucking Fleet 0 Government 0 Retreader 0 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 Agriculture 0 Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> ' V
<br /> A- HAULING AN'D MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 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 m / m / m
<br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (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 01 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations
<br /> 0 0 Other: §
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<br /> Comments
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<br /> . _62081
<br /> INSTRUCTIONS ON BACK ' Correct: ;incorrect. X •A ' 2 3
<br /> White _: - ■
<br /> ■ Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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