Laserfiche WebLink
Tire ftuy & ins ection Re Inspection Report Number <br /> Waste p p <br /> "= State of California I 1 — 1143777 <br /> CIWMB181(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- .O Inspection Type (Fill one) <br /> Site Suffix: v 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �' If Referral,choose referral type(Fill one) <br /> Identifier: 5 AM J �a�w�n COIAV� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> a �e a-z- c Sib inn <br /> Physical Address Sb <br /> 3 3 t,o S c,r <br /> O �Dn GA 1%o% Inspection Date l b <br /> Time In Time Out <br /> Business Rep Title 1 0 0 O AM 0 PM <br /> r O PM <br /> J j c U.�e o�Sc_� Se-rVI w m <br /> Operational 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 /> S Active .40 Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler A Indoor <br /> O Q Inactive S Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q O - - - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> § Y q <br /> Q O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Ll In Compliance - No Violations <br /> Q Q Other: § <br /> Comments1�i <br /> Fac►1� c� r �'r� 'movI,- <br /> J <br /> ,Inspection Form Included: Q 9 <br /> Comments Included: Q �(� ` �` -c ao I -I�&=r--7= <br /> Busin ss Rep's Signature Phone Number Inspect 's Signature hone Number <br /> - — - -- - — - <br /> .,, _,,,_„ 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect. X jl�' I E }f A gLIV <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co :L A <br />