Laserfiche WebLink
F <br /> Waste Tire *rN & Inspection Repo spection Report Number ■ <br /> _ <br /> •� -'�- State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 1 5 - 1 0 1 0 5 '2 2 <br /> California Integrated Waste Management Board - <br /> ryBLUE OR BLACK INK PEN <br /> Part A- Sue <br />} TPID- - Inspection Type (Fill one) <br /> Site Suffix: ' ,C r� ( l 1& Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: „ (nil ii F' icy? tY CHP CIWMB Complaint Educational Visit Other <br /> 4 1 X� itt � L tCY Q Q Q p Q Q <br /> Business or Facility Name <br /> _ Inspected By Inspector <br /> (( `1 <br /> PhysrGal Address LJ `J ) �__�-4 I `i• Vr., i 6 r _s _—� <br /> Street / E-EInspection Date � � <br /> ZIH Gode Time In Time Out <br /> Business Rep Title O AM O AM <br /> j PM <br /> j`� <br /> ,,Operational Status Tire Type Business Role Storage Type <br /> ,. <br /> (Fill one only) (Fill all than apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Q Generator O Outdoor <br /> • ��D Q Closed Q Altered <br /> GPS <br /> Latitude Q Hauler Q Indoor <br /> � Q Inactive Q Truck <br /> Longitude - � , I Q Planned Q 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 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 I Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 00 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q 1 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 I 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 Q Other. § - - <br /> Comments t �{/t .i jt t'r! ► t ( s - ly1' 1 <br /> I <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> I Business Rep's Signature Phone Number inspector's Signature ; ,.: J_Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X `� +< 110 " I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />