Laserfiche WebLink
-- --------------- <br /> lk <br /> A <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California 11 - 1127889 <br /> cIWMB 181(New 04104) Survey Form - Page 1 <br /> callf0mla Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A Survey <br /> inspection Details <br /> Business Profile <br /> TPID- inspection Type (Fill one) <br /> Site suffix: 9 9L E) a I ID Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> (4 CHP OCIWMB oComplaint 0 Educational Visit 00ther <br /> Identifier: 1), 0 <br /> Business or Facility Name Inspected By Inspector <br /> C Es t ofto <br /> Physical Adds <br /> Inspection Date <br /> Time In 0 AM Time Out 0 AM <br /> Title <br /> Business Rep If PM 0 0 PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> at apply) (Fill all that apply) (Fill all that apply) <br /> (Fill one only) (Fill all that Business <br /> Role Storage Type <br /> Y) (Fill <br /> 111 '11 that apply) (Fill all that apply <br /> Tire Count(Whole/PTE) 0 Active 0 Passenger Generator 0 Outdoor <br /> o Closed 0 Alte <br /> GPS Latitude 10/4 0 Hau 0 Indoor <br /> G LOinactive 0 Truck <br /> 0 <br /> 0 Planned <br /> 0 End-Use 0 Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 <br /> Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other <br /> Part B- inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1.HAULING AND MANIFEST REQUIREMENTS ro Notice of Violation 0 Extension <br /> 0 0 1 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Compliance Deadline Extension <br /> ]on <br /> 0 0 1 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date <br /> Ell / [11 / [11 <br /> 0 0 114 CCR§18459.1 -Tire Program ID Number from ClWMB I <br /> (Required for NOV or EXT) <br /> 0 0 114 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 114 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 1 <br /> 0 0 114 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 Referred/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 In Compliance No Violations <br /> 10— 0— Other: § <br /> Comments �Qr�AA1 <br /> 0\zLk-,0n& of fctks <br /> n 0 W__ <br /> 3,�b�e <br /> ed: <br /> Inspection Form Included: 0 <br /> tul <br /> On S�j�_ <br /> Comments Included: 0 ItU hone Nu <br /> Business Rep's Signature Phone Number Ins s�siqn; r <br /> pe <br /> 62081 <br /> 112 3 <br /> INSTRUCTIONS ON BACK Correct:* incorrect:X I X A <br /> White Copy:ClWMB Yellow Copy:Operator Pink C ff: <br />