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FWaste Tire Suy & Inspection Repor 'Inspection Report Number
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<br /> State of California , �7
<br /> CIWM81S1(New04/04J
<br /> USurvey Form - Page 1 1 8 1 0 0 6__t 4_6__
<br /> California Integrated Waste Management Board - -
<br /> Part A S BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: EE� 0 Routine Re-inspection 0 Referral 0 Observation
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<br /> Local ^ If Referral,choose referral type(Fill one)
<br /> Identifier �f i"1 �V 6, C 'Q11 { l�� r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> F_ --- i-_ i Yl.ckc V) i iv i
<br /> F7
<br /> Physical Address r — C. Ed
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<br /> Street
<br /> --� ,-� Inspection Date
<br /> 2
<br /> �-- Time In Time Out
<br /> City State ZIP Code _
<br /> Business Rep TitleAM O AM
<br /> .�- 6°PM M
<br /> �,�r ° .l "Irl l:( y 1 �_✓st � ty { i - au —
<br /> Operational St t s Business Role
<br /> (Fill one only) (Fill all that apply) + r ((tfl ( rely
<br /> Tire Count(Whole/PTE} ��• ; d //pa ,y °;�
<br /> Active (a Generator
<br /> O L(ztSar ,t+' � �rrix k
<br /> 0 Closedt fP (� � �,tit+r�wl
<br /> GPS Latitude �� 1? tt "a1 ra " � 0 'r +� 1/ )
<br /> Hauler
<br /> Inactive
<br /> Longitude 0 Planned
<br /> �. "�a ° ;�Jit, ���a,.• �” r
<br /> Business Type (F ill all that apply)
<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> @,_Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber
<br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Q Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A. I HAULING AND MANIFEST REQUIREMENTS
<br /> 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 . ,°,,^ "F'
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB M 17
<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 O --- -
<br /> 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 I 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
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<br /> plianqe, No ✓�s�laxfons ,
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<br /> Other: § +
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<br /> INSTRUCTIONS ON BACK Correct:* .Incorrect. ` "!' �/ " +( i? w l i 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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