Laserfiche WebLink
== Waste Tire Survey & Inspection Report Inspection Report Number <br /> State rr <br /> CIWM 181(Now <br /> Survey Form - Page 1 1 9 0 2 61 5 <br /> CIWMB 181(Now 04104) ■ <br /> i Cal fornla Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> fBusiness Profile Inspection Details <br /> TPID_ I Inspection Type (Fill one) <br /> Site Suffix: �- �j 7 9 O I 1* Routine Q Re-inspection Q Referral Q Observation <br /> Local �—+ If Referral,choose referral type(Fill one) <br /> Identifier. Sq ti J �Nr �N��J �!7 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` Inspected By Inspector <br /> Physical Address <br /> c/0 L) Arr�y F"',L <br /> • I / ,, I"D �� ����� Inspection Date <br /> /��''•ri11/'� P Time Out <br /> Business Rep � Title Time 1n� O AM O AM <br /> r�,�1{ af~ tiv�Kno O PM O PM <br /> Operational Status I Tire Type I Business Rote :' Storage Type <br /> ff ' <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 1 I � <br /> 3 0 (0 Active i Q Passenger Generator Outdoor <br /> Latitude d Closed Q Altered <br /> GPS I II 10 Hauler Q Indoor <br /> • o Q Inactive I ®Truck <br /> Longitude — I 0 OTR i End-Use ® Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair • 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 /> I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility f ENFORCEMENT STATUS T <br /> • VV = HI�ULING ANO MANIFEST REQUIREMENTS <br /> O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Nctlgll OF.Nlalatl0n Q Extension <br /> O ( O PRC§42953-Contracts With Registered Waste Tire Haulers. lr_ompilgnce 09gdilne l <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Qaxte <br /> 14 CCR 18459.1 a b c -Tire Program ID Number from CIWh48 FoT� <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Requlrepf fot NOV or Q(T) <br /> Q i O 114 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> • O O 114 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Qd 1 CI3NIV�9 Enforcement I <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q �•tlpl-lfiol»ltlgtt� _� <br /> O O1 Other: § <br /> f <br /> Comments 1! 'Jw,,Ui1^ <br /> ..�'�re- <br /> • �1,� 7�Z 7�-� GA ��( 0 04-00oi S, �- <br /> } II►� t�G� I S jrnC�( -� br- /`�15 <br /> — <br /> Inspection Form Included:041s , <br /> ' , <br /> Comments Included: ® ` " ���� <br /> Business Rep's Signature Phone Number I ector's Signature Phone Number <br /> INSTRUCTIONS ON BACK +Cid i �`N11 L�-(�{TJ 1' 2 s2oa1 <br /> White Copy:CIWMB Yellow Copy Operator Pink,Copy:LEA <br />