Laserfiche WebLink
Waste Tire Sw ey & Inspection Report Inspection Report Number <br /> iGll State of California <br /> CIWMB <br /> 181(New 04/04) Survey. Form - Page 1 I 1 - 1143587 <br /> California Integrated Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' SS 1 5 a y - O I lI Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �� Q ��n C�u>n� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address y <br /> J Inspection Date <br /> t oc.�� ori ( A ` 5103 1 <br /> � Time In Time Out <br /> Business Rep Title ' � h 0 AM 0 AM <br /> 5 41111111 PM <br /> U * PM <br /> - — Operational Status Tire Type Business Role Storage Type <br /> _ <br /> Tire Count(Whole/PTE) 3 a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> a Active 0 Passenger Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive Lo' <br /> Truck <br /> Longitude - 0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber 1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 40 Other Lw 4 e_r wet mts, <br /> VVV W <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 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 /> 0 0 Other: § <br /> Comments r 1 <br /> .Lc1 i Irl H� i nS e ' <br /> — — CKC-n. <br /> c 'un r(I- <br /> Inspection Form Included: DI <br /> Comments Included: - <br /> siness ep' ignatur hone Number Inspect 's Signffoature phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: r� � r4 P 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink C py:LE ® 0 <br />