Laserfiche WebLink
Waste Tire SJ*ey & Inspection Reporo Inspection Report Number ■ <br /> -a State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 �_1.. 4 . 10 1 0 6 3 7 <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: ; `1 1 i ® Routine Q 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 /> t Inspected By Inspector <br /> Physical AddressFI i, 1 G /I f i1 : _ r'ld.`a <br /> 4- 1 <br /> �. r'r Inspection Date <br /> Street -2, <br /> -- -' J Time In Time Out <br /> Cih, State ZIP Code _ __ ___ — <br /> Business Rep Title f 10 AM 0 AM <br /> O PM O PM <br /> y <br /> Operational Status Tire Type Business Role Storage T > <br /> o � „ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all tha, <br /> Active Q Passenger Q Generator Q Outdoorr <br /> Q Closed Q Altered1'n <br /> GPS Latitude Q Hauler Q indoor <br /> Q Inactive Q Truck h° <br /> O 1 <br /> Longitude F77 F] <br /> 7_ 1 Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fill all thai 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 /> 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 /> 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 /> M / m / m <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/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 Q In Compliance - No Violations <br /> Q O Other: § - <br /> Comments0I v <br /> - <br /> lCd it rt(M. y -i _J, <br /> Inspection Form Included: Q <br /> Comments Included: 0: <br /> -- <br /> Business Rep's Signature Phone Number/ Inspector's Signature LL Phone Number <br /> INSTRUCTIONS ON BACK <br /> Correct:10 Incorrect: X �/ ,4, �_ .1 2 3 62081 <br /> -- p■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />