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Waste Tire & Ins Inspection Re RInspectwn Report Number
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<br /> Waste p p� _
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<br /> NO
<br /> State B California � 1 6 .�� i 0 0 6
<br /> Cgrated 1steManag) Survey Form - Page 1 '
<br /> California Integrated Waste Management Board �
<br /> Part A- Su ev BLUE OR BLACK INK PEN
<br /> 15
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix j -
<br /> t Q Routine Q Re-inspection Q Referral � Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: , ' j� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected B
<br /> p y Inspector
<br /> Physical Address
<br /> Street -.
<br /> Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title E0
<br /> I � ' t< ® PM • � 0PM
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<br /> L_ r Operational Status(r � !r" ru ' Business Role Storage Typ,
<br /> (Fill one only) tlit#k ' � (Fill all that apply) (Fill all that app
<br /> „ ®Active ( er Generator 0 Outdoor
<br /> O 0
<br /> IGPS Latitude Closed N
<br /> 0 Hauler
<br /> 0 Inactive "" "IN v
<br /> Longitude - 9 r a0 Planned m' 0 End-Use 0 Cqn#'amen
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<br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 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
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<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> VI A HAULING AND MANIFEST REQUIREMENTS
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<br /> Transport of Tires 10
<br /> Notice Of Violation 0 Extension
<br /> 0 0 § g P
<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
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB l
<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 /> I
<br /> 0 Q� 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> @,In Campllance - No Violations
<br /> 0 0 Other: §
<br /> Commentsf Li
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<br /> INSTRUCTIONS ON BACK Correlct: Incorrect: i� � 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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