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Waste Tire Sulky & Inspection Repordoinspection Report Number ■
<br /> �x g i Survey Form - Page 1 1100676 '1
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<br /> AiA State of California
<br /> CIWMB 181 New 04104
<br /> California Integrated Waste Management Board --
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> TPID- Inspection Type (Fill one)
<br /> Site Suffix: Q Routine Q Re inspection Q Referral Q Observation
<br /> Local (1 If Referral,choose referral type(Fill one)
<br /> Identifier: . j Q Complaint Q Educational Visit Q Other
<br /> } — --
<br /> Business or Facility Name t_i �� Inspected By Inspector
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<br /> Physical Address
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<br /> Street
<br /> - f � ) �� '• I' Inspection Date ' '
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<br /> City State ZIP Code Time In Time Out
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<br /> Business Rep TitleMOPM
<br /> OAM 0O AM
<br /> PM
<br /> Operational Status R1,1145;r Business Role
<br /> (Fill one only) (Fill all that apply)
<br /> iii✓/�"fii ' r55Yr�r ✓ �tyr�✓�1�w� a r
<br /> Q Active � � 15� ' � r '� Q Generator
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<br /> D Closed
<br /> Q wd r f��1 5✓8mae � 1/a I5 5y t✓
<br /> Latitude Q Hauler
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<br /> — Planned
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<br /> Longitude Q Pld
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<br /> Q New Tire Dealer h Auto Repair Q Trucking Fleet Q Government Q 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 AND MANIFEST REQUIREMENTS' 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 5
<br /> �q
<br /> Q Q PRC§42956-Registration/Decal in Vehicle m
<br /> Q 014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / I I ' /;m
<br /> Q 1 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 /> ICIWMB Enforcement
<br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q
<br /> Referred
<br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S; In Compliance - No .Violations
<br /> Q Q Other: §
<br /> Comments
<br /> I i r kifi di S.
<br /> t< C'olr
<br /> 11 PISti
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<br /> tion Form..lncluded. /�^`yy..,ar�
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<br /> Comments Included: 0"_
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<br /> Business Rep's Signature Phone Number Inspector s SignaturQ ^,ri � ip� r &1 �:;„
<br /> _ 62081
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X e A PILIE1 It12 3
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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