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' Waste Tire Soy & Inspection Repo nspection Report Number ■
<br /> California
<br /> tate of California A` �J�j `/�i +r� �rtj
<br /> nia Int grat d WasNe Management Board ew 04/04)
<br /> Survey Form - Page 1 ! { 1 0„1 0 5 � y
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> T
<br /> D- [Ell
<br /> Inspection Type (Fill one)
<br /> Site Suffix;, `jr - 0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local
<br /> Id ` t
<br /> If Referral,choose referral type(Fill one)
<br /> entifier: Q CHP Q CIWMB Q Complaint
<br /> Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> I
<br /> t, r
<br /> Physical Address ` rf t • V� t F "l i
<br /> Street Inspection Date
<br /> City State. ZIP Code Time In Time Out
<br /> Business Rep Title O AM O AM 4.
<br /> d`, 0PM � � � OPM
<br /> /' �
<br /> Operational Status t + ry , t y Business Role x°
<br /> '(Fill one only) ' tI) t "i11 (Fill all that apply)
<br /> ., u'' ' ,: »✓ �,rH � �Nr�'d�.'�
<br /> �'EEM I& Active I �``Pr � d�' 1 ® Generator
<br /> 0 Closed
<br /> PS Latitude ry�t4`trprf��rr�PMpptw,r4vu� yt OHaulerG _�T�D
<br /> r'P
<br /> ,
<br /> rr
<br /> inactive
<br /> p ! o f�l"!� +1 a X � k
<br /> Longitude — I r F �^lair O End-Use
<br /> LonLLE Lt
<br /> 9 0 Planned
<br /> ISO
<br /> 0 New Tire Dealer 0 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 j
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<br /> O 0 I,i 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> rin Compliancill No Violations
<br /> 0 0 1Other: §
<br /> Comments j ' —
<br /> t�Ui�"
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<br /> 661
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<br /> — 62081
<br /> Correct; Incorrect: t� ; c � , P � E I Z
<br /> INSTRUCTIONS ON BACK � y,
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © .
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