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: . Waste Tire Sy & Inspection Repor nspection Report Number
<br /> State of California
<br /> CIWMB 1eP r ir — j_V 1 Y fi
<br /> Survey Form - Page 1
<br /> California IntgratdWastManagement Board
<br /> Part A Survey BLUE ORB E
<br /> BLACK N
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<br /> 4TPID- ^� f�} j Inspection Type (Fill one)
<br /> Site Suffix: �� /� �✓ (� f 0 Routine &Re-inspection Q Referral 0 Observation
<br /> Local / ./'` If Referral,choose referral type(Fill one)
<br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name -
<br /> Inspected By Inspector
<br /> Physical Address y l L� / '` `�r
<br /> Street
<br /> C Inspection Date
<br /> City Slate ZIP Code Time In ¢ Time Out
<br /> [--I 0 AMBusiness Rep Title — , L��O PM m . m O PM
<br /> Operational Status t Business Role
<br /> (Fill one only) t � �)� (Fill all that apply)
<br /> (l Active " �� t Q Generator
<br /> O 0 Closed
<br /> Latitude
<br /> , ,�rr^�, 0 Hauler
<br /> GPS �« I,a���
<br /> O
<br /> 0 Inactive r a 1
<br /> Longitude - 0 Planned 0 End-Use «
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<br /> .� "�,.ua a�:.rilX,�f`�:.,a�J6«r:w,�a':�,r, r..�u.�J:n~,,^sr
<br /> a'`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 /> 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 Date0
<br /> 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB M / M / FF '
<br /> 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
<br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement
<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 In Compliance - No Violations
<br /> 0 0 !Other: §
<br /> Comments • ' ` f._ .
<br /> 21
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<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: �/ � , , L
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA `,
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