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■ State of Cali y Inspec Report Number
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<br /> Waste Tire Su & �pection Re ort
<br /> CIWMB181
<br /> asteManage Survey Form - Pagel _1_ _5 - 1 0 1 3 2 6 ;
<br /> California Integrated Waste Management Board
<br /> Part A- Survey _ BLUE OR BLACK INK PEN
<br /> Business 1'rtrfl e ' ilnspectflon Details - -
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<br /> TPID- t ' - Inspection Type (Fill one)
<br /> Site Suffix: `1 t
<br /> ® Routine 0 Re-inspection 0 Referral Q Observation
<br /> Local f r If Referral,choose referral type(Fill one)
<br /> Identifier: !, C,V+•61A"i_-cJ\" ti; 1,4.t^•4" ) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name 1 i !
<br /> t Inspected By Inspector
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<br /> Physical Address `'/ ( Qvl Pa rClAA /
<br /> 1
<br /> 6
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<br /> StreeDO
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<br /> Inspection Date ( / � ( )
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title Q AMQ AM
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<br /> I / k) U L0 r� i O PM _A
<br /> QPM
<br /> (D
<br /> Operational Status tre °( + t Business Role
<br /> r (Fill one only) (Fill all that apply) Ifk�� SpI
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<br /> ® Active !�(� � CY 0`Generator
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<br /> -10 O
<br /> PSLatitude jClosed
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<br /> 0 Hauler
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<br /> _.�O 0 Inactive
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<br /> Longitude - 0 Planned /°, ; M `� � i 0 End Use
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<br /> 0 New Tire Dealer 0 Auto Repair a 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 HAU§ING AND MANIFEST REQUIREMENTS P Notice Of Violation 0 Extension
<br /> 0 0 PRC 42951 -Waste Tire Hauler Registration and Trans ort 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 / FTI / 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 f 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
<br /> In Compliance - No Violations
<br /> 0 0 Other:
<br /> Comments !! y 1
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect X << �/ � A �5 _ 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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