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Waste Tire AA & Inspection Re Inspection Report Number <br /> ssaas. Y p p ------ ----- ---- <br /> ®� State of California 3 - 1006460 <br /> I, <br /> CIWM8181(,New04l04) Survey Form - Page 1 1 3 ' 1 0 0 0 4 0 0 <br /> California Integrated Waste Management Board - __ ___ ___ _ <br /> PartA- Survelllr BLUE OR BLACK INK PEN <br /> } TPID- Inspection Type (Fill one) <br /> Site Suffix } <br /> Routine QRe-inspection QReferral <br /> Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — <br /> Inspected By Inspector <br /> Physical Address ET <br /> —' <br /> Street -- - <br /> Inspection Date <br /> Carty -- State ZIP Code Time In r <br /> � PM Time Out <br /> Business Rep Title � 0 AM <br /> 0 AM <br /> i. O PM <br /> Operational Statustr n Business Role t <br /> I (Fill one only) (Fill all that apply) <br /> twr. <br /> t,4 Q Active Qr� Q Generator <br /> � <br /> GPS. Q Closed <br /> '- Latitude � . .� „��'� <br /> Q Hauler <br /> Inactive <br /> Longitude — . Dia <br /> ? <br /> ? I i Q Planned <br /> t•� a. ,,?,:r r f,i �r, r re m; ^-ya.... l�"r^''�.`r°� ?(F�� ���� f��"�n' 7?> ��;Y��. <br /> +., , ,.,-s:, ,. � ",";'t rrra F?rYrvr»,e? ,r ,al ,f,�' ,. u'knw ^"f�„ rd"~/r s•�".:""Z' : +t� t, � ,; � ,.aa rr:a a ? ���.,`Y � �, <br /> ,. y:.: :.r., r a ,.e nt ,rr.. t,.r...ri� �r ... ;:,his r rat,. :,t , ,�:.....1 .r...,.ar r a. ,.: . '�,C+,...(/.. s t'r�w �..... E ✓. varr z. r" r r:;: <br /> Q New Tire Dealer Q 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 <br /> 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 /> Q 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 /> k° <br /> Other: <br /> Q Q § <br /> Comments <br /> n � <br /> wma <br /> n <br /> INSTRUCTIONS ON BACK Correct:*, Incorrect: I �,; 62081 <br /> ■ - <br /> 1 2 <br /> White Copy:CIWMB Yellow CojSy;O„peratPink Copy:LEA <br />