Laserfiche WebLink
■ Rr .. Waste Tire Suy 8c Inspection Report Inspection Report Number <br /> State of California <br /> 6ti CIWMB181(New04/04) Survey Form - Page 1 i - Q <br /> California Integrated Waste Management a__ _._-... _....._... ......... -._. -i <br /> Part A Survey BLUE OR BLACK INK PEN <br /> I) r4,fMaR�%tl °a <br /> �?s <br />} TPID- � � - � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: IL� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street ( _ <br /> Inspection Date <br /> I"-'-- Time In Time Out <br /> City State ZIP Code _ <br /> DAM <br /> Business Rep Title 0 AM <br /> /! F—F <br /> 0 PM ' 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 /> W;t <br /> v k 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> III�Wlfflwm, <br /> GPS Latitude L� • 0 0 Closed D Altered <br /> ), xI�OI'(t;:e 0 Hauler 0 Indoor <br /> 0 Inactive <br /> O <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS — <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> V <br /> ---- -- -- - ---- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 @14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments - <br /> 1 - <br /> t d> I <br /> } ' <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - - _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: ' ` <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />