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_ . V1 rite The Su ection Report Number
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<br /> St4eo California
<br /> 104
<br /> Waste Manage - Page 1 ----.� aO- r ..VCalifornia anteated Page Form
<br /> ent Board
<br /> Part A Survey; BLUE OR BLACK INK PEN
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<br /> TPID- / s C Inspection Type (Fill one)
<br /> Site Suffix: I £a (9 Routine Q Re-inspection Q Referral Q Observation
<br /> Local �^ _ If Referral,choose referral type(Fill one)
<br /> y Identifier: Q CHP Q CIWMB Q Complaint Q'Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Phys al Address �
<br /> Street r --
<br /> / Inspection Date
<br /> FL
<br /> � �.-�- f .-' ,../ rte?
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title Q AM Q AM
<br /> 0 PM 0 PM
<br /> �G - --
<br /> —'"—'-t Operational Status Tire`Type, s'At Business Role Storage Type
<br /> a; f
<br /> (Fill one only) (Fill all thaf + ' (Fill all that apply) (Fill all that apply)
<br /> I Emu (M Active Q Passe rad D Generator Q Outdoor
<br /> O Q Closed Q AlterkG
<br /> PS Latitude ��
<br /> Q Hauler Q Indoor
<br /> cEm . — Q Inactive Q Tru
<br /> Longitude — _ Q Planned Q OTR Q End-Use Q Container
<br /> meq., p, �� r ,a^ m
<br /> Susi ,esu: ;vpe, (7 I I all :hat apply)
<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 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 STATU S
<br /> V A lHAULING AND MANIFEST REQUIREMENTS
<br /> i
<br /> — - Q Notice Of Violation Q Extension
<br /> Q Q 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 / M / 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/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 Q In Compliance - No Violations
<br /> Q Q Other: §
<br /> Comments45
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �( ,� �, -� - 0 '; d 1 62081
<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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