Laserfiche WebLink
Waste Tire SuQy & Inspection Report Inspection Report Number _ ■ <br /> ty //�'� . �f J <br /> 1x State of California i L 1 1 1 � <br /> �, 4 111 V �! <br /> .m. CIWMB 181(New 04/04) Survey Form - Page <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile !Inspection Details <br /> TPID- 7 t Inspection Type (Fill one) <br /> f Site Suffix: ' - t I I ( f Q Routine Q Re-inspection Q Referral Q Observation <br /> — Q <br /> Local If Referral,choose referral type Fill one) <br /> Identifier: Q CHP Q CIWMB Q Q Complaint Educational Visit —Other I <br /> I Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Street ---- Inspection Date <br /> I ( ` I Time In Time Out <br /> City State ZIP Gode .— <br /> 0 AM 0 AM <br /> Business Rep Title -- O PM — <br /> �1� , 0 PM <br /> t- i <br /> Operational Status re Type Business Role Storage Type <br /> i- _ "`— Fill all that apply) Fill all that a <br /> (Fill one only) (Fill all that apply) ( pp y) ( apply) <br /> Tire Count (Whole/PTE) sry Active Q Passenger Q Generator Q Outdoor <br /> -- -- <br /> r r I wt, ^ .�. <br /> - D Closed Q Altered <br /> GPS Latitude Q Inactive Q Truck Q Hauler Q Indoor <br /> D <br /> �. . Q End-Use Q Container <br /> Longitude - Q Planned T ; <br /> �,. .. <br /> MENA" align: <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 i A HAULING AND MANIFEST REQUIREMENTS _ _ —.—_ Q Notice Of Violation Q Extension <br /> 1 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 1 (a 14 CCR§ 18459.-Responsible Entities Complying with Manifesting Requirements Date m m m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q14 CCR§18460Q Referred/CIWMB Enforcement <br /> .2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 1 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> O Q Other: <br /> Comments <br /> inspection Form Included: Q <br /> Comments Included: Q Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X ,' + A' <br /> _.. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink <br /> Copy:LEA <br /> 4 <br />