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& Ins Inspection Re Or -1spection Report Number
<br /> Waste Tire &lWy p p � 0
<br /> ■ State of California ....__
<br /> CIWM6,81(Newo4,U4) Survey Form - Page 1 1 - 0 .1 0 8 3 a
<br /> California Integrated Waste Management Board
<br /> Part A Surve BLUE OR BLACK INK PEN
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<br /> TPID Inspection Type (Fill one)
<br /> Site Suffix: t �� / ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: f ?. r rr., . r f t'
<br /> . - Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector 1
<br /> Physical Address
<br /> 0
<br /> Street
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<br /> Inspection Date
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<br /> City i State ZIP Code Time In Time Out
<br /> Businl6sS Rep Title OAM O AM
<br /> 0 PM 0 PM
<br /> Operational Status , w` ^
<br /> Business Role �
<br /> (Fill one only) ) k)�tt� (Fill all that apply) gl
<br /> Q Active +xSr)t�1 Q Generator r
<br /> GPS O Q Closed
<br /> Latitude
<br /> 1'� " rr a f
<br /> Arr :�� Q Hauler ( k �"r .
<br /> _ ® Inactive
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<br /> Longitude — Q Planned , �� t,-" Q End-Use
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<br /> ,4w, ;.:m.., r.r `,».t. .1':a;�v"�"
<br /> Q New Tire Dealer Q Auto Repair 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 N
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS 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 IT M 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 IF 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 In Compliance = No Violations
<br /> O Q Other: § --.-_�_
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* incorrect: V, 1 ,M,�l I 1 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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