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Waste Tire Su In Report Number
<br /> ® r�y & Inspection Report � �
<br /> mS'5 State of California
<br /> prnia CIWMB181
<br /> Waste
<br /> eManage) Survey Form - Page 1 i $ - 1 0 0 6 5 6 4
<br /> California Integrated Waste Management Board ., i
<br /> Part A- Survev BLUE OR BLACK INK PEN
<br /> TPID- Inspection�/ � - Inspection Type (Fill one)
<br /> Site Suffix:
<br /> 116 Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: .0 CHP Q CIWMB Complaint Q Educational Visit Other
<br /> Business or Facility Name T -
<br /> Inspected By Inspector
<br /> Physical Address _,_-_.- — I J
<br /> :/ 1
<br /> Street
<br /> `) t Inspection DateEEI
<br /> `City State ZIP Code Time In Time Out
<br /> Business Rep Title (jP AM0 AM
<br /> �0PM � ' L �� ® PM
<br /> Operational Status n m Business Role rYy' tr.
<br /> (Fill one only) lr (Fill all that apply)
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<br /> Q Active r tpt, Q Generatorf
<br /> Latitude D Q Closed Q Hauler
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<br /> Longitude - Q End-Use
<br /> Q Planned r
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<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 /> QService Station QHauler QAgriculture QShredder
<br /> ® Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A LIN PRC
<br /> G AND MANI 51 -Waste eE 8T R RQUstration REMEN and
<br /> S Transport of Tires ' _ . __
<br /> Q Q § g. Q Notice Of Violation Q Extension
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14`CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date;m / m FTI
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required'forNOV 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 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations
<br /> Q Other:
<br /> Comments / `
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect. , I � 62081
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