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Waste Tire Su" y & Inspection Reportal.3pection Report Number,
<br /> " state B California Survey Form - Page 1 1 0 2_5 850
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<br /> ^i CIWMB 781(New nage 9 _ --`�
<br /> California Integrated Waste Management Board
<br /> Part A Survey BLUE OR BLACK INK PEN
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<br /> TPID- f *7 �7 -7]— Inspection Type (Fill one)
<br /> Site Suffix: / / y i� ' Routine Q Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: �. t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name l� Inspected By Inspector
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<br /> Physical Address
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<br /> Street
<br /> r- (^ t. Inspection Date
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<br /> /1v State ZIP Code Time In Time Out
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<br /> Business Rep Title PM Q PAM M
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<br /> Operational Status Business Role L
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<br /> �•) l Active Generator
<br /> D 0 Closed
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<br /> GPS Latitude 0 Hauler1F
<br /> 0 inactive
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<br /> Longitude - —� 0 Planned 0 End-Use g�✓�f
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<br /> ?D New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> 4 T
<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 TUS
<br /> V I A HAULING AND MANIFEST REQUIREMENTS O
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation 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 -S.�jbmittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
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<br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> i
<br /> 0 0 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 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (a In Compliance - No Violations
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<br /> 0 0 Other: § -
<br /> Comments
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<br /> INSTRUCTIONS ON BACK 'Correct: Incorrect: , "v �/ q �A , , I 2^ 62081
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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