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Waste Tire SL& & Inspection Repor nspection Report Number
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<br /> ' �� State of California �
<br /> CIWMB 181(New Survey Form - Page 1 1 11} 5 - 1 0 2 5 5 5 3
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<br /> Cal ifornia,Jntegrated Waste Management Board
<br /> a Part A- Survey BLUE OR BLACK INK PEN
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<br /> TPID- ^ /� Inspection Type (Fill one)
<br /> Site Suffix: ( '� .� [',7W.? (� f - &Routine Q Re-inspection Q Referral Q Observation
<br /> Local ii--�-„- ^� ---����-----`moi^ / If Referral,choose referral type(Fill one)
<br /> Identifier: � ,- t;.,^ £�, �` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name t Inspected By Inspector
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<br /> Phystcal Address
<br /> Street [�E] EuFE
<br /> Inspection Date /
<br /> City
<br /> State ZIP Code (Tiimme1In� Time Out M 0 AM
<br /> Business Rep r` Title 0 AM [
<br /> O PM 0 PM
<br /> Operational Status f n r M Business Role
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<br /> Active �� r�7 >r* Generator a�ptdt" t r
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<br /> GPS Latitude O O Closed �� ) aI OSI} "pbiyN "
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<br /> O Q Inactive .r1uz � ���wr: � ''"y�r7Tx') i
<br /> Lon etude - tF it,�E iii Q End Use � I9wti ;
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ( Government Q Retreader Q Dismantler Q Tire Derived Fuel
<br /> Q Used Tire Dealer Q 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q ExtensionI
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m
<br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> O O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O 1 O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> Q O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> O Q Other: § 5
<br /> Comments r f
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<br /> Inspector s signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:IS X; !! k 62081
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<br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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