Laserfiche WebLink
Waste Tire Suilvey & Inspection Report Inspection Report Number ■ <br /> i14 Slate of California I 1 - 1127857 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey_ <br /> Business Profile Inspection Details <br /> - - - _ <br /> TPID- 1 Inspection Type (Fill one) <br /> Site Suffix: �"� 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local C_ If Referral,choose referral type(Fill one) <br /> Identifier: � �X��` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> hy & Lm a rcjjc ,� ���-fi t-► - i o A 1�►�,td, �t M btJ(e� <br /> Physical Address <br /> — <br /> �__ JJR� Inspection Date I <br /> `' � Time In Time Out l <br /> Business Rep Title ®AM AM <br /> I O PM 1 L� 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f <br /> ®Active assenger a Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive *Truck I <br /> Longitude - Q Planned If OTR Q End-Use Q 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 ® Other �icnc yc-II tc <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMEN STATUS <br /> V q 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 -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 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 /> Q Q Other: § <br /> Comments / f� <br /> Inspection Form Included: Q <br /> I _ <br /> Comments Included: <br /> Business Rep's Signature Ph-one Number n p t,r's i ture ----Ph-one-Number <br /> — - — - .- 62081 <br /> INSTRUCTIONS ON BACK Correct:10 Incorrect: V l- 1 : z 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy LE © ■ <br />