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., Inspection Report Number
<br /> Waste Tire SLWy & Inspection Repor ■
<br /> State of California
<br /> CIWMB 181( e ) Survey Form - Page 1 LI -4 - � Q 13793
<br /> California Integrated WasttManagee Management Board _-.
<br /> Part A- Surve BLUE OR BLACK INK PEN
<br /> TPID- ., � Inspection Type (Fill one) _ � •� �� ���
<br /> Site Suffix: E:
<br /> (. f_i r i® Routine 0 Re-inspection 0 Referral 0 Observation
<br /> Local _ If Referral,choose referral type(Fill one
<br /> Identifier: J
<br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other
<br /> Business or Facility Name Inspected B
<br /> I � P Y Inspector
<br /> Physical Address ;1 y I (Al
<br /> ('.(•
<br /> : _ l
<br /> Street 4 � Inspection Date
<br /> City -�- State ZIP Code Time In Time Out
<br /> Business Rep Title 0 AM 0 AM
<br /> r r _ 0 PM 0 PM
<br /> 1 W
<br /> Operational Status y6 1 , Business Role �' �r ' ,
<br /> A(Fill one only) jI)CJI raly) (Fill all that apply)
<br /> Irtr � y
<br /> (D Active ( �"}�c� � " 0 Generator 't td4 r
<br /> Latitude D 0 Closed
<br /> GPS `� Hauler
<br /> a
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<br /> Inactive
<br /> O "r" ttf�
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<br /> Longitude - 0 PlannedEnd-U ra� )i, (` °r 0 se � I
<br /> .,10
<br /> 'Pr
<br /> 4 „,v'"; k
<br /> 'i,,v�i�t r,�..+,4: "r,,.��,W
<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 (j 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 /> V
<br /> 0 Notice Of Violation 0 Extension
<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 1:11 / M / I:El
<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 -
<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 a,In Compliance - No Violations
<br /> 0 0 Other: §
<br /> Commentsj j ,r r
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<br /> 62081
<br /> INSTRUCTIONS ON BACK Correct: Incorrect: i I it 'LZ
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<br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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