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,t Waste Tire SU In Report Number
<br /> @� icy & Inspection Re�port�-- p �
<br /> ®®R" State of California "
<br /> ClWMB asteMana a Survey Form - Page 1 �.t.._ 3 - 1 0 1 3 3 0 0
<br /> California Integrated Waste Management Board
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> TPID- r, 1 m Inspection Type (Fill one) '
<br /> Site Suffix: l �4 t ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local y, If Referral,choose referral type(Fill one)
<br /> Identifier: �;.I y� off !!(x't 0 CHP � CIWMB � Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
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<br /> Physical Addressio, C C2
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<br />� Street -
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<br /> Inspection Date
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<br /> City State ZIP Code Tn ime In Time Out
<br /> Business Re 0 AM P t5— Title jOPMM = 0 AM
<br /> Q PM
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<br /> Operational Status Y ,r�, ( " ,r Business Role
<br /> ( (Fill one only) + "�; r`krfl (Fill all that apply)
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<br /> '[ +":wa+ fd1r"tr r),r�r( h " + rytirt 2 + ✓r{�Y "i1 )) ria yr rtr r 1 vaf„.
<br /> ,;r f�"��,•;�f „�I)r.,*�}r r rr�`�rs��+ �� � a,.,�'rs.,,�`ar�m���� ✓� a ��;' �,?,„�tij � Active �+,���� t1��r� 0 Generator
<br /> I —( � — —O � r r�'iG-01���r w�.r�' f�°r 4 e Irv: ti.✓ r;
<br /> 0 Closed �a, r. I '���i�) f? r4urR✓
<br /> Latitude ,a ✓ rind
<br /> GPS �--� �rtid� i v Hauler
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<br /> 0 0 Inactive W+iC '"l " ` �r yl^, J rrrnr,r ran vr�r
<br /> Lon itude — `' " t 0 End Use
<br /> 9 0 Planned t� lfitnr
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<br /> 0 New Tire Dealer Auto Repair 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 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Haulei Registration and Transport 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 / M / 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 I CIWMB Enforcement
<br /> 0 0 14 CCR§18461 Manifest
<br /> 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 /> 0 In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct: r Incorrect: "!o60` / 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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