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s ection Report Number
<br /> Lai
<br /> Was,teaTire Su�y & Inspection Repor __ pp Survey Form - Pagel 1 �3066 � 3CIWMB 181(New 04/04) � � N
<br /> California Integrated Waste Management Board .. .-..... .-
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> y_tr,W 7a pp/r y tl"arn i1yr
<br /> TPID- m Inspection Type (Fill one)
<br /> Site Suffix: —t r✓ Q Routine Q Re-inspection Q Referral Q Observation
<br /> Local �''� If Referral,choose referral type(Fill one)
<br /> Identifier: �,� r � r, t /J�' O CHP Q CIWMB Q Complaint O Educational Visit Q Other
<br /> Business or Facility Name y Inspected By Inspector
<br /> I ? (1/"/l. �� !c^� i !/
<br /> Physical Address �— <:4
<br /> f
<br /> Street Inspection Date 13J
<br /> me In Time Out � I
<br /> City State ZIP Code Ti__
<br /> Business Rep Title f ® AM Q AM
<br /> f / 0 P QPM
<br /> Operational Status ,„ Business Role
<br /> Fill one only) Fill all that apply)
<br /> t
<br /> ( Y) (
<br /> r�r'
<br /> Active , r ' ns ® Generator
<br /> O
<br /> Closed
<br /> GPS Latitude El
<br /> Irrr> f r w lbw nr�br AJ ri 'V r rynr�
<br /> O Hauler yttMdgrr,r
<br /> O inactive i b rr r1s / narrr)rrb.
<br /> 0
<br /> C'b'nLongitude Q End-Use Planned )8rner
<br /> 1,11''I'' 1 1121,01, 131; s! 11g1111111111il
<br /> �.__ .�. LLU LI—LI-1-1
<br /> ,
<br /> 0 New Tire Dealer Q Auto Repair ® Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel
<br /> Q Used Tire Dealer 0 Auto Body O Car Dealer Q Collection O Crumb Rubber
<br /> Q Service Station Q Hauler O Agriculture Q Shredder O 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 /> Q Notice Of Violation Q Extension
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> 0 Q 14 CCR§ 18459 Responsible Entities Complying with Manifesting Requirements Date M / m / lE
<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 /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> 0 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 /> a In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments
<br /> IF
<br /> o
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<br /> 62081
<br /> INSTRUCTIONS ON BACK ',Correct: `Incorrect: ,diL. 1 a
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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