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Waste TireQ&y Sc InSpeCtl®ri Ikeftlinspection Report Number
<br /> si■ZLS State of California ! - - -- r ■
<br /> - --
<br /> CIWMB
<br /> 181
<br /> New 0 Survey Form - Page 1 10 2 5 7 4 �
<br /> Cafifornia Integrated Waste Management Board _ - _ _ '.
<br /> Part A- Surve
<br /> Business Profile Inspection Details BLUE OR BLACK INK PEN
<br /> - Inspection Type (Fill one)
<br /> { Site Suff
<br /> TPID- ix: / I I (, I '�� - f C> ! '
<br /> '0 Routine ® Re-inspection Q Referral Q Observation
<br /> Local If Referral,choose referral type(Fill one)
<br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other
<br /> Business or Facility Name
<br /> Inspected B -
<br /> p y Inspector
<br /> Physical Address j r/ - F/
<br /> I
<br /> L? /
<br /> Street
<br /> Inspection Date
<br /> City State ZIP Code I Time In Time Out
<br /> Business Rep Title Q AM 0 AM
<br /> EEI ��_�OPM �� QPM
<br /> I
<br /> i t Operational Status rr Business Role Storage Type
<br /> ore Count (Whole/PTE) (
<br /> T
<br /> (Fill one only) �� Fill all that apply) (Fill all that apply)
<br /> (D Active fc��Ei Q Generator Q Outdoor
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<br /> GPS LatitudeLEI - — Q Closed ( , r
<br /> Q Hauler Q Indoor
<br /> _ _ Q Inactive r* 1a dM
<br /> O AY'rl
<br /> Rude - f p
<br /> Lon Q End Use Q
<br /> Longitude Q Planned �+4�� w ry w)�, �� Container
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<br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel
<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 /> VV A HAULING AND MANIFEST REQUIREMENTS
<br /> Q Notice Of Violation Q Extension
<br /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date
<br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB
<br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT)
<br /> Q Q 14 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 Q Referred I CIWMB Enforcement
<br /> Q O 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
<br /> Q In Compliance - No Violations
<br /> §Q Other:
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<br /> Comments
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<br /> r r � r
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<br /> Inspection Form Included: Q
<br /> Comments Included: Q _
<br /> Betsiness Rep's Signature Phone Number Inspector's Signature Phone Number
<br /> s _
<br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �;I A ,reed L i L n j 1 62081
<br /> White
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<br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■
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