Laserfiche WebLink
Waste Tire Sul _ Jy & Inspection Report Inspection Report N. -nber <br /> '�•�• State of Catifornia A " I• 11 <br /> •,S'�i <br /> CIWMB 181(New 04104) Survey Form - Paige 1 10 1 ,� 0 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: \ ? J l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Cv� ,w✓%�� � Lo Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> 11 Inspection Date \ ` Z j3 t✓ �f <br /> Time In Time Out <br /> Business Rep Title ® AM O AM <br /> ��1✓) 1 0 PM l 7— ✓ U @ PM <br /> V\ <br /> � � - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � �— <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - 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 ® 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 PRU§N9 AND MANIFEST R REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O Hauler sand 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 iQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FT] <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or Exr) <br /> Q iQ 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?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 <br /> ® In Compliance - No Violations <br /> O O (Other: § - <br /> Comments <br /> k LT L <br /> Inspection Form Included: 0 <br /> _ I <br /> Comments Included: Q - - - <br /> Business Rep's Signature Phone Number Ins ector's Signature Phone Number <br /> � _1 J� 62081 <br /> INSTRUCTIONS ON BACK . Correct: Incorrect �/� l � x .a t� PLIE! 1 'j z � <br /> White Copy:CI1,V1.113 Yellow Copy Operator Pink Copy:LEA <br />