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■ Waste Tire S y 81: Insp@CtlOn Repo Inspection Report Number <br /> r3 . - ■ <br /> iii➢ State of California -` -' <br /> _ .- <br /> CIWMB ISI( e ) Survey Form - Page 1 _- 0 <br /> California Integrated WasttManage <br /> Waste Management Board - . _ <br /> 06 49 <br /> Part A- Survey <br /> y � BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ? -� - C ;° <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> Name - - - <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> _ Time In TiOut <br /> - I m F__ E <br /> _ <br /> City State ZIP Cade me f _ _ <br /> Business Rep Title <br /> 0 PM 0 PM <br /> --1 : LT_ I <br /> no FzU <br /> Operational Status Business Role f� T��� ^ <br /> 1f (Fill one only) �tli„ A (Fill all that apply) t ( � ` <br /> ,�a,� <br /> .,, Q Active iaaf? � I Q Generator Yrl�f4 x, * <br /> Q Q Closed <br /> PSLatitudeGQ Hauler <br /> Q Inactive <br /> +, <br /> v• <br /> i <br /> -p "yakvyflrr ?fid ?,?vN� ars: i ( � <br /> N 0 <br /> Longitude - Q " r ,r " Q End Use r( faettrf?tt, <br /> Planned <br /> 7&NNewire Dealer Q Auto Repair (Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Agriculture Q Shredder Q Other <br /> — <br /> Part - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A` HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 Q <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 & 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEx <br /> Q Q l'' 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 Re#erred!CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End Use Facilities <br /> Q Q A14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 1 Q In Qornpliance = No Ytolations <br /> O Q Other: § <br /> Comments, <br /> a <br /> f"^ re m r r ail„ t p <br /> �T <br /> E'��� �raw✓,�. N sN - +b� �?` vCt�i v µ � P' " { 1,�" r, � �" 4 ? d r� <br /> INSTRUCTIONS ON BACK [MCbrrect:I* Incorrect: A 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />