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■. Waste Tire SulPy & Inspection Report0nspection Report Number
<br /> _ - - _ ■
<br /> State of California f i
<br /> _ tion CIWMB 181( e ) 8 - 1 0 0 6 6 3 0 1
<br /> California Integrated WasttManagSurvey Form - Page 1 11
<br /> e Management Board _ _ _-.i
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> } TPID- Inspection Type (Fill one)
<br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier:
<br /> v. :y�- •. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name ` --- -
<br /> Inspected By Inspector
<br /> PhysicalAddress �. F-&
<br /> .
<br /> Sheet
<br /> Inspection Date � (I _ �_] /
<br /> city 1 � State Zip Code I Time In _ Time Out 0 AM
<br /> Business Rep Title Q AM t
<br /> 0 PM `i -� G PM
<br /> Operational Status �) �)�� Business Rolee
<br /> " (Fill one only) wM1 t � (Fill all that apply)rommi IEEE=j ? / C1 atI
<br /> l l� RRw ( r
<br /> Q Active ��/ ,rQ Generators ttftdri R )
<br /> 0 0 Closed
<br /> GPS
<br /> Latitude
<br /> = - E � t t � irPt ti/
<br /> a�'�n %xpd�i . w"'�y '4 /�9 ✓d ye y n
<br /> 00 Hauler inactive 1t n�,��
<br /> r d
<br /> Longitude
<br /> �
<br /> 0 Planned �'� � � tai 0 End Use
<br /> 7 1 tifn C s. a d��' t latir
<br /> ��rtrnl:prrry^ -a rcpt t r m, i'°r't'•'' "'� 1 ri ,app. ,� r m ri .G .; ',,'µ tr^-, m „„;, 5 7 +" 4ei y ✓ „,. r^
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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 Q Agriculture 0 Shredder _-&.Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> VA 1 HAULING AND MANIFEST REQUIREMENTS
<br /> 0 Notice Of Violation 0 Extension
<br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m IT] / IE
<br /> 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
<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 0 In Compliance N t�sl E�r18°
<br /> 0 0 Other: §
<br /> Comments -
<br /> Inspection Form Included: 0
<br /> Comments Included: 0
<br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X � - 3 62081
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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