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Ins ection ort Number
<br /> Waste Tire Su' y & Inspection Repor p _Report
<br /> ;, 6:6Lra State of California
<br /> California Int grat d1Was e81 eManagelment Board Survey Form - Page 1 i Y o i L
<br /> Part�y{A- SurveBLUE OR BLACK INK PEN
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<br /> - Inspection Type (Fill one)
<br /> Site Suffix: _� �. ' ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: . Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name I
<br /> Inspected By Inspector
<br /> Physical Address 7
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<br /> Street
<br /> <~i ( ( Inspection Date
<br /> city State ZIP Code Time In Time Out
<br /> Business Rep Title — - O AM 0 AM
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<br /> Q New Tire Dealer Q Auto Repair 0 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 /> U A HAULING AND MANIFEST REQUIREMENTS Y ,Violation
<br /> Part B - Ins ection of Waste Tire Dealer, Generator, Hauler and End-Use Facilit i ENFORe EMN STATU_S Extension
<br /> Q Q § g p O
<br /> 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 m / m / Q
<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 to Compliance - Na Violations
<br /> Q Q (Other: §
<br /> Comments , - - --- - --
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<br /> Comments Included:
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> - 62081
<br /> INSTRUCTIONS ON BACK Correct:* ,incorrect: X
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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