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® Waste Tire S Ay & Inspection Reporf Inspection Report Number
<br /> ". State of California +
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<br /> CWMB 1 teManage Survey Form Page 1 8 - 1 0 1 0 6 6
<br /> California Integrated Waste Management Board Y _- - -Part -
<br /> p A Surve BLUE OR BLACK INK PEN
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<br /> } TPID- _ Inspection Type (Fill one)
<br /> Site Suffix: � '' � � � C r '
<br /> ' <� -� ' ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local , ^) If Referral,choose referral type(Fill one)
<br /> Identifier: ) i ;t ;�'{ !l .i y.� f tri-c vt 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected -
<br /> p d By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> Code Time In Time Out �� i
<br /> 9
<br /> Business Rep Title 00 AM 0 AM
<br /> PM 0 PM
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<br /> Operational Stat Business Business Role
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<br /> Active 1 151 ���^ @ Generator � tr�✓ I
<br /> CIPS Latitude Closed
<br /> Hauler
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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 @ 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 HAULING AND MANIFEST REQUIREMENTS j
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension
<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 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
<br /> 0 0In Compliance
<br /> Other: §
<br /> Comments p
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<br /> Incorrect 62081
<br /> INSTRUCTIONS ON BACK Correct: ; ' , ,
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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