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nspection Report Number
<br /> Wp�te Tire Suf y & Inspection Repor I ■
<br /> aState ohCalifornia
<br /> Cgrated Waste
<br /> Survey Form - Page 1 - 10"
<br /> -3
<br /> 2 99
<br /> California Integrated Waste Management Board _. _.._._ -
<br /> Part A,- Surve BLUE OR BLACK INK PEN
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: / LI U' G� - C Routine Q Re-inspection Q Referral Q Observation
<br /> LocalIf Referral,choose referral type(Fill one)
<br /> Identifier: 0 &i (l Cl CO_Lll s')_1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> --
<br /> Business or Facility Name t ' Ins ected B
<br /> P p Y Inspector
<br /> - Physical Address
<br /> 13:11 - LAs], -d
<br /> v tl . l_ f(t t__f
<br /> i Street
<br /> - Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> 0 AM
<br /> Business Rep Title f [I
<br /> IQ AMU� % Y FE
<br /> 0 P � � 0PM
<br /> lGL
<br /> Operational Status i t r r Business Role
<br /> (Fill one only) ��) r�� (Fill all that apply)
<br /> ® Active r ® Generator
<br /> �+ Latitude - Q Closed r'Ql�. t '"a4. rr , `
<br /> GPS « J+ «i"J�fd Q HaulerLL
<br /> 1� C{J4rr
<br /> p";
<br /> r w'v9Jry rill twr nrr
<br /> ._ Q Inactive „�r`'rltri
<br /> Longitude
<br /> End Use t �OdtWatn
<br /> Q Planned
<br /> J11neS rl {is + � &t � 41
<br /> rT r v
<br /> I
<br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government i#,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
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A HAULING ANDIMANire#REQUIREMENTS
<br /> 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 /> iQ Q PRC§42956-Registration/Decal in Vehicle
<br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date EDE] / 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
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<br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators
<br /> Q Q Other:
<br /> Comments
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<br /> INSTRUCTIONS ON BACK "-Correct:0 Incorrect: ry AW � _ 62081
<br /> ■ Whiter — _- _ © ■
<br /> Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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