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Waste Tire SuNey & Inspection Reporo_Inspection Report Number ■
<br /> °'•� State of California
<br /> °rnia CIWMB 181(New
<br /> Manage) Survey Form - Page 1 L-I 4 - 0 10 3California Integrated Waste Management Board ---. ---- -- -- � - -�-�- '
<br /> Part A Survev
<br /> p BLUE OR BLACK INK PEN
<br /> pectlQrk 56N,J0,�J:>x.,,.uw. 011"122"z'!"!
<br /> �
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: t..:_ r�� �.�` & Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local rx If Referral,choose referral type(Fill one)
<br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> _ Inspected By Inspector
<br /> Physical Agdless { ! t �'+' t {{r'r('
<br /> Street >
<br /> Inspection Date
<br /> CifyState ZIP Code Time In Time Out
<br /> El- ..J
<br /> Business Rep `" Title O AM O AM
<br /> } < �'q t A Cj;V(" �--� PM m PM
<br /> Operational Status Business Role
<br /> (Fill one only) (Fill(Fill all that apply) II( 1atly1
<br /> a r L � rfir al S
<br /> 0 Active ' a 0 GeneratorIt�fotal/
<br /> 4 �#a�'I °f°�","rrl��+^yiM)�*✓� f� n"�����a""�F`-" �i""
<br /> ® Closed
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<br /> Latitudew, aryb r"funJt aae/i✓J, rv ,rx 3 rx r a
<br /> ! 0 Hauler
<br /> — 0 Inactive
<br /> Longitude - 0 Planned r" End Use i
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<br /> 0 New Tire Dealer 0 Auto Repair 0 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 'I HAULING AND MANIFEST REQUIREMENTS
<br /> O 0 0 Notice Of Violation ,0 Extension
<br /> PRC§42951 -Waste Tire Hauler 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 /> I
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 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/CIWMB Enforcement
<br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _
<br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations
<br /> 0 0 Other: § ---- — --
<br /> Comments 1-A
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<br /> ;. . "r 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: r
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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