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<br /> ■ onspection Report Number
<br /> -: . yy�!te Tire Su
<br /> y & Inspection Report _ �
<br /> ifornia ll
<br /> uBS.w71.' CIWMB181(New 04104) Survey Form - Page 1 Q 3 4 7
<br /> California Integrated Waste Management Board ---- -- ----- --- ---
<br /> Part A Survey BLUE OR BLACK INK PEN
<br /> gF wr 1 Rr r a"v M
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<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffixr QObservation Routine Q Re-inspection QReferral
<br /> Local .. If Referral,choose referral type(Fill one)
<br /> Identifier: O CHP Q CIWMB O Complaint O Educational Visit O Other
<br /> Business or Facility Name
<br /> Inspected By Inspector
<br /> Physical-Address j `J — Fill
<br /> 11- -_
<br /> - .3 A)—(
<br /> Street
<br /> -- Inspection Date
<br /> `
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title O AM O AM
<br /> - 0PM _ 0P
<br /> Operational Status ti i t ,p Business Role tth;(/8 T ps
<br /> ti/ }i,�;' / pw ra ^°a(Fill one only) rt)Ialw G (r �1 (Fill all that apply) r�III� ( tky'
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<br /> r��"r
<br /> Activer���� � ,Xi�I Q Generator77T7
<br /> 0
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<br /> Closed
<br /> Latitude
<br /> Hauler� C'r r r,,yr rX
<br /> 1 I 1 Q Inactive
<br /> o (� ar�'' p� Jk
<br /> X
<br /> Longitude — O Planned r � r'r'iaw End-Use
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<br /> :,,7�....y..°.<�a`., ..w,.�s ,""°�a,..w,"v "r. ,'�� t t ..:r r_,><_...�.�:aa. ,,,�
<br /> O New Tire Dealer Q Auto Repair O Trucking Fleet Q Government O Retreader Q Dismantler Q Tire Derived Fuel
<br /> Q Used Tire Dealer O Auto Body Q Car Dealer O Collection Q Qrumb Rubber
<br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other
<br /> PartB - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V r A HAULING AND MANIFEST REQUIREMENTS
<br /> O O O Notice Of Violation Q Extension
<br /> 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 1 PRC§42956-Registration/Decal in Vehicle
<br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements 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
<br /> O O (Required for NOV or EXT)
<br /> _ — — -
<br /> 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 0 Referred I CIWMB Enforcement
<br /> Q 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations
<br /> 0 0 Other: ---
<br /> Comments
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<br /> :,m
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<br /> , 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect ' �/ �IAT L
<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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