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Waste Tire Su4by & Inspection Report Inspection Report Number
<br /> GBSS� State CIWMB California
<br /> grated Waste
<br /> Survey Form - Page 1 _
<br /> California Integrated Waste Management Board I
<br /> 0692
<br /> PP art A- §u ry ey BLUE OR BLACK INK PEN
<br /> xr,mk r=_,.... '=21
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<br /> } TPID- �• �f ���� rn I Inspection Type (Fill one)
<br /> Site Suffix:
<br /> Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: ! y x_( I 1 _, t
<br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility —
<br /> I r,r Inspected By Inspector
<br /> Physical Address y /
<br /> f
<br /> Street
<br /> Inspection DateEE
<br /> City State ZIP Code I Time a In _ Time Out
<br /> Business Rep Title O AM 0 AM
<br /> 0 PM 0 PM
<br /> Operational Statustr y f Business Role ��
<br /> (Fill one only) w� i� ►� � (Fill all that apply)
<br /> �l�:rur"r ax n� r r'n h' urMyarro rCttq r,��S ire ^'
<br /> q r ri1{ 4"a ar l l✓✓ r" aw w r wrt q'" r�`tr~'`"" "M
<br /> 0 Active l '/d 0 Generator
<br /> Latitude — __0
<br /> ..O & Closed
<br /> GPS 0 Hauler gft�
<br /> —O Inactivetn
<br /> Longitude d4Y,fxa t
<br /> q'.
<br /> 0 Planned r$r ���Qd �tt End Use ���ffh
<br /> t� �ert 4�,r Mc"�rrddfr� �x Y r l i"M,,rr�a tidh x%dCr" M'itaf4dr'i.
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<br /> 0 New Tire Dealer 0 Auto Repair 0 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 A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation 0 Extension
<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 ,'
<br /> 0 0 14 CCR§18459.1 (a)(b) (c)-The Program ID Number from CIWMB LE ; m /'m
<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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators c_; In Compliance - No Violations
<br /> 0 0 Other: § -
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: " { �a , ,a 3 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LEA
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