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spection Report Number
<br /> Waste Tire Sur* & inspection Report in ■
<br /> Q State of California CIWMB181
<br /> asteManage Survey Form - Page 1 1 -- 0 1 3 3 9 -$
<br /> -"California Integrated Waste Management Board - - _.
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: '� ✓ ( (A Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier:, r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name ; Inspected By Inspector
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<br /> Physical Address / 7(--
<br /> Street
<br /> Inspection Date
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<br /> city State Zip Code/ +, l Time In Time Out l —
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<br /> Business Rep Title M : L�_—�O PM O PM
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<br /> -- Operational Status n eK r' Se b" r ' Business Role
<br /> (Fill one only) µ, 11( iI"IM �IrF (Fill all that apply)
<br /> D ® Active Q Generator
<br /> Latitude 0 Closed
<br /> CPS Hauler
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<br /> L—Li O inactivei1 1^:
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<br /> Longitude � � � 0 Planned `� rrr, Q End-Use
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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 /> Q 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
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS
<br /> VV A HAULING AND MANIFEST REQUIREMENTS
<br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires (a;Notice Of Violation 0 Extension
<br /> 0 j 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 `J
<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 Q Referred/.CIWMB Enforcement
<br /> g 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 Q In Compliance - No: Violations
<br /> 0 0 Other: §.
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<br /> Comments _
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 62081
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