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® AWaste Tire Suoy & Inspection Report ,__ Inspection Report Number ■
<br /> State of California
<br /> irnia ClWMB asteMaage Survey Form - Page 1 ` Q 2 5 6 D 7 J
<br /> California Integrated Waste Management Board ( .._.
<br /> Part Af - SurveBLUE OR BLACK INK PEN
<br /> u 11,1111:53111:
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: 1 0 rs 10 Routine ® Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier ` a !j Q CHP Q CIWMB Q Complaint O Educational Visit O Other
<br /> Business or Facility Name -
<br /> Inspected ByInspector
<br /> Physical AddressL E�
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<br /> U --s i
<br /> -� -�- F
<br /> Street T
<br /> Inspection Date O
<br /> City State ZIP Cade Time In_ Time Out
<br /> Business Rep Title O AM Q AM
<br /> } ._._ O PM 0 PM
<br /> Ina slisaii Operational Status Pr Business Role as
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<br /> Active Generator
<br /> O
<br /> LatitudeClosed
<br /> GPS
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<br /> Q Hauler "� ,° �,"��t
<br /> O O Inactiveeb
<br /> Longitude - OL WMf Q End Use �� nl(„tr
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<br /> O New Tire Dealer O Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel
<br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber
<br /> O Service Station O Hauler O Agriculture Q Shredder @ Other r r L .
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS v
<br /> V A HAULING AND MANIFEST REQUIREMENTS
<br /> Notice Of Violation Q Extension
<br /> 0 O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> O O PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / m
<br /> i
<br /> O O 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 /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years
<br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement
<br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators I
<br /> Q In Compliance No Violations
<br /> Q Q Other: §
<br /> Comments
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<br /> INSTRUCTIONS ON BACK [Correct: Incorrect. l ��� � � 1 �'�+, 62081
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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