Laserfiche WebLink
Waste Tire Sul,, ,y & Inspection Report Inspection Report Number <br /> State f•1iiB <br /> CIWMB <br /> 181(New <br /> Survey Form - Page 1 I - 1140804 <br /> CIWMB 181(New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 (J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> i Identifier: 6C417 �i.is_�ti,��; IQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Nam - (/— Inspected By Inspector <br /> Q�t���nee / rze%4"r G <br /> Phys cal Address 3 — <br /> ' !'�NILE'�6t�'C�•�'try <br /> Inspection Date Z <br /> Time In Time Out <br /> Business Rep Title <br /> *AM ® AM <br /> G a 0 PM O 0 L9 0 PM <br /> rX <br /> 'Operational Status' Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ ® Active ® Passenger ® Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use I ® Container <br /> Business Type (Fill all that apply) <br /> QNew Tire Dealer QAuto R <br /> e air Q Trucking Fleet QGovernment Q Retreader Q Dismantler Q Tire Derived Fuel <br /> i <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 ® Other <br /> - <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 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 m /'m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 Q Referred/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 in Compliance No Violations <br /> O Q Other. § <br /> Comments <br /> Inspection Form Included: X <br /> Comments Included: Q <br /> ® Ar <br /> Business ep's Signature Phone Number nl spector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct, Incorrect xuj i f 2 3 6208 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop V <br />