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Waste Tire 44y 8c Inspection Repo
<br /> Inspection Report Number
<br /> ■ ➢itiiSS➢ State of California ---
<br /> 181( ) Survey Form - Page 1 9- - 10
<br /> V 6 V 0 Y
<br /> California IntegratedWaste Management Board I
<br /> I
<br /> Part
<br /> IA- Surve BLUE OR BLACK INK PEN
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<br /> ��TPID- _ Inspection Type (Fill one)
<br /> I Site Suffix:
<br /> T Routine 0 Re-inspection 0 Referral Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: t`,~ - /� �J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date CR
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<br /> t� �— { State ZIP C Time In Time Out
<br /> Business,Rep Title O AM
<br /> l ' � O AM
<br /> 0 P 0
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<br /> ^;,¢,�;«: d r✓� Operational Status¢✓r> 'r" BUSIneSS Role
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<br /> t� ® Active Q Generator
<br /> 0 Closed ,
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<br /> Inactive "� f� t " 1
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<br /> Q 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 HAULING AND MANIFEST REQUIREMENTS 0 NoticeOf Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> p
<br /> O O ,
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle m
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / J I I /`m
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB II II II
<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 COR§"18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> 0 0 r 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> 0 0 % 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 0 1' 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations
<br /> jOther:0 0 § --- — - ----
<br /> Comme is -
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<br /> �;� k - ---i°-- 62081
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<br /> INSTRUCTIONS ON BACK Correct:* Incorrect Ahd4 L
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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