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Waste Tire Su�y & Inspection Report nS.pection Report Number ■
<br /> v 'wAStG9 State of California __ - ..----------- _.. n
<br /> CIWMB181
<br /> Waste
<br /> eManage) Survey Form - Page 1 1 0 0 6 6 2 8
<br /> I California Integrated Waste Management Board I
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> _
<br /> Spo�u ► r"I , a'r��rn" ' r k n< Vr r n
<br /> r
<br /> TPID- t Inspection Type (Fill one)
<br /> Site Suffix: '� _ � ��11:1,
<br /> ��'
<br /> 0 Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local e If Referral,choose referral type(Fill one)
<br /> Identifier: ` ti ,_:.\ 4-V 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected By Inspector
<br /> Physical
<br /> sical Address
<br /> Streit 4Y
<br /> Inspection Date
<br /> City State ZIP Cade Time In Time Out_ `
<br /> Business Rep Title 0 AM
<br /> 0 AM
<br /> m G PM j . ' 0 PM
<br /> n i
<br /> 6� J L. f tr
<br /> 6111111 ell , Operational Status ,
<br /> Business Role
<br /> y t, (Fill one only) (Fill all that apply) l�llr (1af�dply)
<br /> Q Active � r (a Generator ( 'C Ultt'bat
<br /> 0
<br /> GPS Latitude O Closed l� ����
<br /> �q„"i� � a��� 0 Hauler 0 indoor
<br /> 0" war #luAr
<br /> O0 Inactive
<br /> Longitude — 0 Planned p+ 0 End-Use DContainer
<br /> 0 New Tire Dealer Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel
<br /> Q 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 0 Notice Of Violation 0 Extension
<br /> V
<br /> 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date F11 / FF1 / [11
<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 § Y q 9 P 9 years
<br /> -0 - I
<br /> 0 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3
<br /> 0 14 CCR 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred/CIWMB Enforcement
<br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities
<br /> 0 i 0 14 CCR§18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations
<br /> 0 ' 0 Other: §
<br /> Comments
<br /> ti r \ v 7
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<br /> INSTRUCTIONS ON BACK Correct:* [Incorrect: 62081
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<br /> I ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■
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