Laserfiche WebLink
Waste Tire Sufty & Inspection Reporf -",p c on Report Number <br /> ■ <br /> State of California 11 — 1088331 1 0 8 8 3 31 <br /> CIWMB181(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board V -- — —C <br /> o — <br /> Part A- Survey _ <br /> BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - - <br /> TPID- / / Inspection Type (Fill one) <br /> (� <br /> Site Suffix: / �4 v �' ` Q Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> If Referral,choose referral type(Fill one) <br /> ( . t Q Complaint Q Educational Visit Q Otherdentifier: <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> to 0 <br /> Inspection Date �� <br /> State ZIT Code Time In Time Out <br /> O <br /> Business Rep Title AM <br /> Q AM <br /> M <br /> � <br /> FOPM <br /> ✓LC'_ �r �I � ',__ �f�iiatI /t` ,`,# � p <br /> .„'Oerational Status Tire Type <br /> Business Role Storage Type <br /> ^ (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) CJ <br /> Q <br /> r <br /> _ A-ct—ive Q Passenger <br /> n <br /> ger Q Generator Q Outdoor <br /> � � losed Q Altered <br /> Ops Latitude CQ Hauler Q IndoorL� �ET OQacl O End-Use Q Container <br /> Longitude - �� 1 ,� _� Q Planned Q OTR <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 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 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 1 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days - (Required for NOV or EXT) -- <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I 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 Q In compliance - No Violations <br /> 0 0 Other: § - — - y <br /> Commentsc tQ. r '/� �e 6 � j: Cs } <br /> r.IPtayJ�U, CSC tit6 �l }'�,,-o 0 1 `�Q 0(one Ct oI ✓1;'t �c< or rc vvk <br /> Inspecton Form included: Q <br /> 5Si`ria"tore Phone u`rrtref spe igr <br /> g !n ctor's'S tature Phone Number <br /> _ ® <br /> 62081 <br /> M <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ' <br /> V � 'A r' 1-„C; <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />