Laserfiche WebLink
■ `rE. . Waste Tire Sl y & inspection Repor Inspection Report Number ., . <br /> EEE State of California <br /> EEE Survey Form - Page 1 1 2 - 1 0 0 6 75 7 <br /> .;, ..: CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Surve , BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O + Inspection Type (Fill one) <br /> Site Suffix: 4 1 <br /> + (0 Routine Q Re-inspection Q Referral Q Observation <br /> Local 'If Referral,choose referral type(Fill one) <br /> Identifier: ji �(�CI (�f �.-) �� 6 Q CHP Q CIWMB. Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name/ Inspected By Inspector <br /> Physical Address 0 <br /> Street <br /> Inspection Date G <br /> ! Cf <br /> I k ,�� t 1 U5 <br /> City State, ZIP Code Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> 1l I - � - /- [a] 0 PM rJ J G U 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count <br /> ( ,❑° L3L L)i QActive Q Passenger Q Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q) Hauler Q Indoor <br /> O Q Inactive !ts Truck <br /> Longitude — Q Planned OTR ('E) End-Use Container <br /> Business Type (Fill all that apply) <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 /> -------------- <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / F7 <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 /> -- -- . .------------- .. - ..._..... <br /> Q Q — <br /> 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 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 7 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments / r ; r .. t G r r /• i_,�::r / <br /> Li( . �;t 1 icy, z luca�� UUt Il C� ( r i <br /> I :t ' 411 i�7 )/?l J .fi� ViI?JJ \ t; { <br /> [nspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Ins ector's Signature Phone Number <br /> • 1 <br /> Correct: Incorrect: 62081 <br /> INSTRUCTIONS ON BACK ) 'r♦ r 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />