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■ Inspection Report Number
<br /> Waste Tire Suy & Inspection Repori ■
<br /> i
<br /> State of California
<br /> as CIWMB 181( e ) Survey Form - Page 1 1 4 - 1 0 ! 1) 4 7
<br /> Californiania Integrated WasttManagement
<br /> Waste Management Board ._. _.-. -..
<br /> Part A- Survey BLUE OR BLACK INK PEN
<br /> Business Profile Inspection Details
<br /> TPID- ( Inspection Type (Fill one)
<br /> Site Suffix: l 6 ® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: ,:<<:: "i Or?'—_e r^�ac.[lz- r 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected B
<br /> . p Y Inspector
<br /> Physical Address
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code Time In Time Out
<br /> Business Rep Title O AM / F
<br /> PM OAM
<br /> O PM
<br /> I�
<br /> ' ►'f}, ,;#D1t{�.; . t
<br /> Operational
<br /> I Status rre l l
<br /> Business
<br /> I Storage
<br /> Tae
<br /> (FI oneonly) (FII IhaI ( ll all that apply) (Fill all apply)
<br /> `J ® Active 0 Passage, Generator 0 Outdoor
<br /> gib
<br /> D 0 Closed 0 indoor
<br /> 0 Hauler Alterel`I)f"fE
<br /> GPS Latitude p)°r
<br /> 00 Inactive 0 lluekr�(���
<br /> I T]4
<br /> Longitude - Planned0 OT R yF �r 0 End-Use 0 Container
<br /> �. ., ter. �•,.^, :r• ,;.;.�, __
<br /> Business Type (Fill all that apply)
<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 0 Agriculture 0 Shredder 0 Other
<br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS
<br /> V A '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 /> i
<br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline
<br /> 0 0 PRC§42956-Registration/Decal in Vehicle
<br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> 0 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 or EXT)
<br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years j - -
<br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<br /> i
<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
<br /> Q In Compliance - No Violations
<br /> 0 0 'Other: §_-----
<br /> Comments 1'
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<br /> INSTRUCTIONS ON BACK Correct: Incorrect I a 62081
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<br />' White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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