Laserfiche WebLink
U731�5�l3t55 <br /> Waste Tire SurveyA Inspection Report Inspection Report Number <br /> • =''1° <br /> State B181(Nrnla Survey Form <br /> - Page 1� � � 1 7 - 10 7. 3 4 7 1 <br /> .Cgrated ast.Ma ager Y <br /> California Integrated Weste Management Board�. <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details, <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one). <br /> Identifier:. _ -j-tiG� ,,Jv ( ,, , �_ Q CHP Q CIWMB Q.Complaint Q Educational Visit Q Other <br /> Business or Facility Name _. �- Inspected:By Inspector <br /> ` <br /> Physical AddYss <br /> (Street <br /> Inspection Data <br /> City State Z!P Code Time In Time Out <br /> Business Rep Title __••ee ��J-����,Code <br /> . O AM Q AM <br /> a PM 0 PM <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 /> ° Q Active Q Passenger ..Q Generator Q Outdoor <br /> l 0 ®Closed Q Altered <br /> GPS Latitude W,� Q Hauler Q Indoor <br /> �I� �TI� O Q Inactive Q Truck <br /> Longitude - L�J�L__J• � O Planned Q OTR O End Use Q Container <br /> i <br /> Business Type (Fill all that apply) <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 •Other <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility RENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts'witti Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements Date / m <br /> O O 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§.18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred!C-IWMB Enforcement <br /> O O 14 CCR§118461-Manifest System Requirements for Waste Tire End-Use.Facilities _ <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire.Generators ®In Compliance - No Violations <br /> O 1 O 1 Other: §, <br /> Comments <br /> �-tres -4 Yc— --�xaia—cvsN►�-hn'S ¢wU_F�_.— TL/1) s•,F;ll <br /> G( -� f° �x --�is�.•t,t�, G 2� -TP I D��,..,>�•r.Lu cldca.L <br /> Inspection Form Included:Oi A/ eo OGZS' <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number Inspector's Signature- Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A Ah P L E; 11t213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />