Laserfiche WebLink
Waste Tire Su, .y & Inspection Report Inspection Report Number <br /> - 7 /�r�J <br /> Stateof edCalifornia Survey Form - Page 1 I 1 Q f 9 3 4 8 <br /> CIWMB 181(New 04/04) <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: / V Z' - V / 0 Routine ®Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: �� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business /Fa ity NameInspected By Ins ector <br /> Ph ical As <br /> Inspection Date o6 / o,3 O '� <br /> Time In Time Out <br /> Business ep TitleO AM 0 AM <br /> �WM l.J � � � �PM <br /> -- - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count( ole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 6-3 ® Active 0 Passenger ® Generator Outdoor <br /> 0 Closed ®Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other , 7d �f1}C" `SWT <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> L 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 rn <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FCr/ � Me ? <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB II"� II -- II <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 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 O In Compliance - No Violations <br /> 0 0 Other: -- <br /> Comments <br /> - a <br /> Inspection Form Included: 0 ,\ <br /> Comments Included: 0 - <br /> usina 's ure Phone Number I ector's Signature_ Phon u ber <br /> INSTRUCTIONS ON BACK ' reC E:`k( A'hk P <br /> 62oa1 <br /> White Co :CIW Yellow Copy:Operator Pink Copy:LEA <br />