Laserfiche WebLink
Waste Tire Sue & Ins ection Report Inspection Report Number ■ <br /> Y p <br /> State of California I 1 - 1143775 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ _-. BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- ^^ C Inspection Type (Fill one) <br /> Site Suffix: 5 d 8 J $ © I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: SupJ all) COUD Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> -- <br /> Inspection Date 1 O <br /> S-�0&ko� GA qS�o� 1 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> tt C 0 PM 0 PM <br /> S vlr to n JI � rn�l n�l U- -- - - - - <br /> -- - -- - y- - Storage Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> Q Active Passenger ® Generator Outdoor <br /> D ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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-1 AI 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-Regis trationlDecaI in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7)— <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive 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 ® in Compliance - No Violations <br /> Q Q Other: § <br /> Comments ►Ur1 <br /> lns eComme is Included: �I1 — --(oCV_"-LlO.O�JI <br /> P \¢ <br /> lBusiness Rep's Signature Phone Number Inspe is Signature hone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:40 Incorrect: <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy: ® ■ <br />