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Ins Re
<br /> Waste Tire Suy & Inspection Reporpection ort Number
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<br /> ■ .° Wa St ate of California I ..,� ..._
<br /> "°° CIWM6181(New04/04) Survey Form - Page 1 2 - 10 1 0 6 1 0
<br /> California Integrated Waste Management Board -- - - -- -- - -- --
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- n, Inspection Type (Fill one)
<br /> Site Suffix: t( + 5 (a Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Q.tn 0a {I(\ aQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical Address /L_yt.trc
<br /> Street
<br /> Inspection Date
<br /> City T State ZIP Code Time In Time Out
<br /> Busiq{Hess tRep ( Title 0 AM PM [ ' 0 AM
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<br /> 1 i 'Operational Status �r, 't It,�„'` a' : Business Role
<br /> (Fill one only) ^� ' Il�tatk (Fill all that apply)
<br /> Active Q�Generator
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<br /> O Q Closed
<br /> IGPS Latitude "� t
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<br /> ,a� � r� Q Hauler
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<br /> Q Planned
<br /> Longitude Q End-User
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<br /> Q New Tire Dealer Q Auto Repair 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 s.
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS 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
<br /> 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 O In compliancg No Violation
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect r J _ 62081
<br /> ■ Whitel Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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