Laserfiche WebLink
Waste Tire Suriby & inspection Report inspection Report Number <br /> W t <br /> State of California <br /> CIWM6181(New04/04) Survey Form - Page 1 ��„ 1 0 4 1_6� <br /> i a <br /> California Integrated Waste Management Board - BLUE OR BLACK INK PEN <br /> Part A- SurveyMA <br /> _ <br /> Business Profile <br /> in Dt�l, ,A <br /> TPID- j Inspection Type (Fill one) <br /> Site Suffix: ! L � QRoutine Q Re-inspection Q Referral Q Observation <br /> _.Local <br /> - _ If Referral,choose referral type(Fill one) <br /> 1den4ifier: j I '�" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ( Inspected By Inspector <br /> Physical Add ess <br /> L <br /> Street Inspection Date �] <br /> Cit State _�7_iP C—ode T1 Time In Time Out <br /> Business Rep Title �-- O PM . f I 0 AM <br /> ij : F, ( � O PM <br /> -„� h,t Operational Status Tire Type Business Role Storage Type <br /> -,11111111 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> Tire Count(Whole/PTE) y , <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> _ 0 @ Closed Q Altered <br /> GPS LatitudeLL Q Hauler Q Indoor <br /> _� �_..�:�.__L_L_-1—=-10 Q Inactive Q Truck <br /> �. .—_ <br /> Longitude — � 1 , 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> Q Q § Manifest System Requirements Registered Waste Tire Haulers ! Q Referred/CIWMB Enforcement <br /> 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3 ears <br /> Q Q 14 CCR§18460.2 Man y q -- - I <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 /> f <br /> Comments Uv_ d,t i ra { i t ( y-j 1"J ✓t, 1 / <br /> IIf,tom A­ <br /> nspection Form Form Included: 0 <br /> Comments Included: Q' Inspector's Signature Phone Number <br /> Business Rep's Signature Phone Number p 9 - <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X I Lr L I 11 I <br /> White Copy:CIWMB Yellow Copy:.Operator Pink Copy:LEA <br />