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<1ns action Report Number
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<br /> Waste Tire Suy & Inspection Report p pStatof California / jJ�j �jrJ'�r �)f �JCaliforIn181(Ne Manage)ment Board Survey Form - Page 1 i. 10 _i L 5 i i
<br /> Part A Surve� BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)J
<br /> Site Suffix: 1 ? ' l I L ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: �QC't t (d p;-I ) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name U Inspected By Inspector
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<br /> Physical Address —r �� L
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<br /> Street (� Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title IFUO AM 0 AM
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<br /> Operational Status Business Role10011
<br /> (Fill one only) ," 1�t� :r (Fill all that apPIY)
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<br /> Q Active r Generator
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<br /> O Closed
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<br /> GPSfiryty Q Hauler
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<br /> Q Inactive fw ,vi �r�f)�atrl
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<br /> LongitudePlanned
<br /> I 9 � Q PI a n n ed Q End Use
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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 a Auto Body Q Car Dealer Q Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other
<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 Q Q Notice Of Violation Q Extension
<br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<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 / FT] M
<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 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 L 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 tplattons
<br /> Q Q
<br /> Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Ah l L 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■
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