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Waste Tire Su & Inspection Repori"pection Report Number
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<br /> =� State of California
<br /> 6mrnia CIWMB 181(New
<br /> Manage) Survey Form - Page 1 1 0 1 0 1 3 7 1 8
<br /> California Integrated Waste Management Board _ _
<br /> Part A CK INK PEN
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<br /> TPID- L ! � r1 , Inspection Type (Fill one)
<br /> Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: ` y
<br /> C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name E Inspected B
<br /> p Y Inspector
<br /> Physical Address 1 __T7_1 L /p'Ld?�_ `_
<br /> L = v"fir �v Oji
<br /> Street
<br /> Inspection Date ;'1 , El Y State ZIP Code I Time In Time Out
<br /> Business Rep
<br /> Title - } QAM 0 AM
<br /> PM �
<br /> ` I� Operational Status A ►� #t Business Role
<br /> u � (Fill one only) tar" (Fill all that apply) (( 1{ ��a�
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<br /> Active rr„ �� r” Generator
<br /> �
<br /> GPS Latitude [� . Q Closed
<br /> Mr wVb ✓" fl M �� 1/ M
<br /> Q Hauler
<br /> Q Inactive
<br /> Longitude —
<br /> g Q Planned i "" , ,e,rec Q End-Use � ff� rts" >.
<br /> Q New Tire 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 Q Car Dealer Q Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder (D Other / r
<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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers.
<br /> Compliance Deadline "
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m / m m
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<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 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> �P Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments I
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<br /> Comments Included: Q - - '�
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> �" 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � V I xT. _-1 2
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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