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spection Report Number
<br /> Waste Tire Sufi & Inspection Repor
<br /> State of California ,� �/ -Jf j
<br /> California Int grat d,81 Waste Management Board Survey Form - Page 1 i 1 V L. i ... j
<br /> Part'A Survey BLUE OR BLACK INK PEN
<br /> 14
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: (_L Q Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: �J- - `'! , „ �-� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or acility Name- Inspected By Inspector
<br /> Physlc`aalrAddress p �. ,' ! Cr ( (�Zt,
<br /> Street Inspection Date TA
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<br /> Time In Time Out _
<br /> City State Zip Code Ti_. _—_
<br /> Business Rep Title Q AM m � AM
<br /> 0 PM ' O PM
<br /> I -
<br /> -�I
<br /> Operational Status�� /N/ 4 Business Role t
<br /> �r (Fill one only) � ll fir' � (Fill all that apply)/ �f
<br /> ra �wd!a ,� �+,.,��
<br /> Q ActiveA.� °s� i/N Q Generator
<br /> — - 0
<br /> � - Closed
<br /> IF
<br /> Latitude
<br /> QHauler
<br /> I
<br /> Q Inactive
<br /> Q End-Use Rude Q Planned
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<br /> esxttess �_ au.'r �
<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 FacilityENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> Q Q
<br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements
<br /> Q Q
<br /> 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB Date M / F-F] / M
<br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q Q �
<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 ( In Compliance - No Violations
<br /> Q Q Other: § .------- -
<br /> Comments
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<br /> INSTRUCTIONS ON BACK Corriect:* incorrect: '( r � ' Ir i � 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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