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Waste Tire S y & Inspection Repore_Inspection Report Number ■
<br /> ° ^•'' State of California
<br /> � �� - i
<br /> CIWMB 181(New 04104) I
<br /> Survey Form, Page1
<br /> California Integrated Waste Management Board I_ -
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: �a p' 7 /�( - ' ® Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: `) #z �. _^r; i. �;y , Q CHP Q CIWMB Q Complaint Q (Educational Visit Q Other
<br /> Business or Facility Name
<br /> - Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date K
<br /> City —_ (11 1 State Zlp Code I Time In_ _ Time Out
<br /> Business Rep / Q AM
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<br /> l O PM
<br /> Title � b! O PM
<br /> Operational Status « Business Role
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<br /> ® Active ' ® Generators "� '/t)
<br /> EU Q Closed
<br /> GPS Latitude D "tYr'r. Q Hauler
<br /> Q Inactive
<br /> LongitudeEd-Use i Q Planned
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<br /> QNew Tire Dealer QAuto Repair Trucking Fleet QGovernment QRetreader QDismantler
<br /> Q Tire Derived Fuel
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<br /> Q Used Tire Deal r Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber
<br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other
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<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> A HAULING AND MANIFEST REQUIREMENTS Q Notice Of ViolatioQ Extension
<br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
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<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements
<br /> Q Q
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (^W m m
<br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requned farNOV or EXT)
<br /> Q Q 1114 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
<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
<br /> Q Q Other: §
<br /> Comments .f+
<br /> Inspection Form Included
<br /> Comments Included:
<br /> Q Business Rep's Signature Phone Number Inspector's Signature Phone Number ~I
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<br /> INSTRUCTIONS ON BACK Correct:16 Incorrect: X F V, L_ In I, 2 .j 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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