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Waste Tire Suiay & Inspection Report*Inspection Report Number
<br /> State of California
<br /> same
<br /> CIWMB Waste
<br /> eManage) Survey Form - Page 1 - 1 0 1 4 8 4 9
<br /> California Integrated Waste Management Board
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> 12.1
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<br /> TPID- -;�-� Inspection Type (Fill one) '
<br /> Site Suffix: �, = Z (6 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local - If Referral,choose referral type(Fill one)
<br /> Identifier: �^ ) 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected B
<br /> p_ p Y Inspector
<br /> Physical Ad o ress
<br /> Street
<br /> Inspection Date
<br /> :
<br /> City State Z!P Code
<br /> cam.. _ Out
<br /> _ — � I Time In Time _
<br /> Business Rep Title Q AM f 1 Q AM
<br /> j/gin, IE LLIOPM L-1._I � 0 PM
<br /> _j LO erational Business Status r BusiRole
<br /> b�
<br /> t (Fill one only) lc (jf (Fill all that apply) 1 (✓ r�f` P
<br /> Active �� r��� »"1 Q GeneratorA 1ttto�
<br /> per+
<br /> G1- Latitude Q CIOSedr� lf
<br /> Jr rirlr'r,»J »r ✓ry/ w rNa m rt1 rro
<br /> Olnactive 0 Hauler vrltij r ,
<br /> ---- , �����* r'�� t.
<br /> � i Ja rae)rr � h1 § w�
<br /> Longitude — '» r» r a rR a», Fr7ri✓f »m r
<br /> 9 0 Planned t �i' End Use
<br /> �
<br /> Q 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
<br /> 0 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 m El
<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 orEXT)
<br /> i
<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 T
<br /> In
<br /> Compliance - No Violations
<br /> Q' p at�ons
<br /> 0 0 Other: §
<br /> Comments I
<br /> ? a
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/� A M P t 2� 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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