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Waste Tire SurAy & Inspection Report _ �spection Report Number ■
<br /> State of California ICIWMB �y }f'1}
<br /> California Int grat dt81 WastJe Management Board Survey Form ew 04/04) - Page 1 �1_-, -_--- - .� 3 3 V V
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> rpr�pF¢' .r j»fr° 1�5 £ 'n
<br /> �"k "�1taN tor^
<br /> �r�r
<br />` TPID_ Inspection Type (Fill one)
<br /> g-
<br /> Site Suffix: Q C7, z , (0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> _-Fi
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: 177
<br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> C+' State ZIP Code Time In Time Out
<br /> Business Rep Title I—� O AM 0 AM
<br /> O PM _ 0 PM
<br /> Operational Status Tire Type Business Role Storage Type
<br /> (Fill one only) (Fill all that ap (Fill all that apply) (Fill all that apply)r
<br /> IN f1'
<br /> 0 Active 0 Passengett I; 0 Generator 0 Outdoor
<br /> r
<br /> O (9 Closed 0 Altered h,
<br /> Latitude
<br /> GPS q, - 0 Hauler 0 Indoor
<br /> 0 Inactive 0 Truck
<br /> Longitude – 0 Planned a OTRI 0 End-Use 0 Container
<br /> O ror~
<br /> �,Bysiness Type (Fill Ball that apply)
<br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 0 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 ^ENFORCEMENT_STATUS
<br /> V A T HAULING AND MANIFEST REQUIREMENTS 1
<br /> 0 0 PRC 42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension
<br /> § 9 p I
<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 ;M
<br /> m
<br /> 0 ! 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<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 1 0 Referred/CIWMB Enforcement
<br /> 0 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 f
<br /> Q In Compliance NO
<br /> 0 0 Other: §
<br /> Comments I ,
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<br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: i ) %v � 1i 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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