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Waste Tire Su&y & Inspection Report Inspection Report Number
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<br /> •' State of California
<br /> CIWMB f (New 04104)
<br /> cal,fornIntgratdWaseManagement Board Survey Form - Page 1 { Aa0 V 0 ry
<br /> 1
<br /> Part A Survey BLUE OR BLACK INK
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<br /> TSite Suff PID-
<br /> ix: - t �Inspection Type (Fill one)
<br /> _; S i.) t
<br /> ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local ''
<br /> y � If Referral,choose referral type(Fill one)
<br /> Identifier: E +^'({�{t ��„ l ,
<br /> k' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Ins ected B
<br /> r p y Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code
<br /> Time In Time Out
<br /> Business Rep Title 1 l O0 AM 0 AM
<br /> PM 0 PM
<br /> y Operational StatusC Business Role �q �
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<br /> 0 Hauler ,Pr � Nt a
<br /> 0 Inactive
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<br /> 0 Planneda/uq�MJird 0 End Use �q
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<br /> 0 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 ® Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility1`STATUS
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> 0 I 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV orEXT)
<br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years --- --- ---
<br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CIWMB Enforcement
<br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> 0 0
<br /> Other: §
<br /> Comments 1 )/r'r( 1 7l r�1 /1� ft��' ' L.d i i t ' ! '//�r ' 1
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<br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: r 62os1
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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