Laserfiche WebLink
■ CLUE c Waste Tire S y & Inspection Repo •Inspection Report Number - <br /> L'SBB�. State of California — .- <br /> CIWM6181(New 04104) Survey Form - Page 1 1 8 . 1 .01 0 l' 3. 8 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE.OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI - <br /> Site ( Inspection Type (Fill one) <br />} Site Suffix: S U <br /> @ Routine Q Re-inspection . Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one). <br /> Identifier: y( ��((��}) 1„(F � "1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address I \ �14 ri_ <br /> Street f �� � ��� Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM <br /> m • m PM EE 0 PM <br /> OAM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) a /_ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 !� 1 . Active q) Passenger Ia Generator @ Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m • Q Hauler. Q Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned Q OTR Q 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 (0 Other I i (<wt� Y'(r . <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ': A 'HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation Q Extension <br /> Q i Q I PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q i Q P(2C§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 Dater� / M15 <br /> / EE <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 TireTrp Logs within 90 days/. (Required for NOV or EX7) <br /> s <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/CIWMB Enforcement <br /> Q 14 CCR.§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments j <br /> ('t ,!/� . <br /> t 11'1t Qcya-yf 4D r rr+ � �� , �?>�C,1�-�c'n {�c' a0Cl r C� e <br /> � '_U ' CJt7 1 r f1P�J 0k1Cl tai��' LtlC��le ltrf� Dt� ��4' QTc'. <br /> Inspection Form Included: ': <br /> Comments Included: Q -- _'...__ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACKCorrect:0 Incorrect: X) � ; AIMp ,� Old <br /> 62081 <br /> ■ White Copy:CIWMB Yellow'Copy:Operator Pink Copy:LEA ® ■ <br /> v <br />