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■ Waste Tire Sdo. y & inspection Rem Inspection Report Number ■
<br /> State of California . i
<br /> CIWMB181(New 0""0 ) Survey Form - Page 1 # A� - 10 .a +/� 51 9 i
<br /> California Integrated Waste Management Board - -
<br /> Survey -- N
<br /> Part A
<br /> TM1 fi µwar W 't+w i" ' 4xinSpectlOn Details.r E
<br /> BLUE OR BLACK INK P
<br /> -{{ Inspection Type (Fill one)
<br /> Site Suffix: I / I(i� / �! I 41 / (f Routine Q Re-inspection Q Referral Q Observation
<br /> TPID- }
<br /> Local `` If Referral,choose referral type(Fill one)
<br /> Identifier: f_ 1 }' `r CHP CIWMB Complaint Educational Visit Other
<br /> Business or Facility Name {
<br /> Inspected By Inspector
<br /> Address Physical Ad i ( — -- _
<br /> y r ( t V C
<br /> Street
<br /> Inspection Date 1
<br /> I <._ t 1 ✓ '; �—=� 1 : I _ I Time In Time Out
<br /> City I• State (P � __.
<br /> Business Rep �( Title O AM O AM
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<br /> ( ' EH : LL---...l0PMm � m QPM
<br /> ,o7'Operational Status ,w ar� rr Business Role
<br /> (Fill one only) 1 (Fill all that apply) r
<br /> ( Active " (2) Generator
<br /> -.BGU P�InS.e..s
<br /> Latitude
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<br /> .Clr.poa.sed.at
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<br /> `Hauler
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<br /> Q Inactive
<br /> Longitude Q Planned End-Use
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<br /> Q New Tire Dealer Q Auto Q Dismantler �rr'Q
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<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 />
<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
<br /> Q Q PRC§42956-Registration/Decal in Vehicle
<br /> 0014 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / /
<br /> 14 CCR 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT)
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days �
<br /> .
<br /> Q 214 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 "Referr IWMB Enforcement
<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 MO ° '
<br /> Q Q Other: §
<br /> Comments - l
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<br /> Inspection For Included
<br /> comments t ._. .._ .,- ., _.. .. .,. . _ " ... .f_,_ 1. _-
<br /> Business Rep's Signature Phone Number Inspecor s Signature Phone Number ;
<br /> _ -
<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:*. Incorrect: X �/ li �X�A MIP,a L I L- 1 0 �
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA
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