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Waste Tire Sy & Inspection Repor Inspection Report Number ■
<br /> -OySS.m State of California
<br /> � `Cgrated Waste
<br /> eManage) Survey Form - Page 1 , 9 i 0 0 0 7 4 i
<br /> CaliforniarialntegratedWasteManagementBoard _—_�
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> N'e�r
<br /> TPID- 7 L' {- r_ Inspection Type (Fill one)
<br /> Site Suffix: L _ _ �� - �; Q Routine O Re-inspection O Referral O Observation
<br /> Local I t If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical AddressF1I I t l -
<br /> 1 _ -
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<br /> Street f4 Inspection Date a /
<br /> City ll State Z/P Code Time In — Time Out
<br /> Business Rep fTitleI Q AM Q AM
<br /> Q PM Q PM
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<br /> LLA�LA
<br /> Operational Status Business Role.„,fyrr,MrM
<br /> (Fill one only) (Fill all that apply)
<br /> ® Active Q Generator � )yt
<br /> O O Closed fd✓ ra,f���
<br /> �+��+ Latitude C ;M"rra ',�r r, O Hauler
<br /> O Inactive i f ' (,erre r " t fti rare
<br /> Longitude - O Planned ,/ O End-Usef
<br /> ..
<br /> O New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer 0 Auto Body O Car Dealer O Collection Q Crumb Rubber
<br /> O Service Station Q Hauler O Agriculture 0 Shredder ( Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AN-6-MAN IF-EST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements
<br /> I Date-
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> m m m
<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 0 Referred/CIWMB Enforcement
<br /> I
<br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators in Compliance No �'tolation�
<br /> _
<br /> O O Other: §
<br /> Comments i
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<br /> INSTRUCTIONS ON BACKCorrect:* Incorrect:
<br /> White --- --
<br /> ■ Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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