Laserfiche WebLink
AWaste Tire S Avey & Inspection Reporo Inspection Report Number ■ <br /> State of California 9 F4 r+; �j <br /> n® CIWMB 181(New )4/04) Survey Form - Page 1 ° 'f } � i <br /> 3 <br /> m z <br /> CaliforniaIntegrated Waste Management Board � - -_.-- --- - --_ -_ -: <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> _TInspedlon D�;tat <br /> TPID- Inspection� � � _ [0al Inspection Type (Fill one)SiteSuffix: r Routine Q Re-inspection Q Referral Q Observation <br /> LocalQ� �� If Referral,choose referral type(Fill one) <br /> Identifier: t�� CP <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Inspected <br /> Physical Address <br /> 1 _-- t C2 to <br /> street - -___. —1 <br /> Inspection Date L—' 1 ' q 2 <br /> jjj �f <br /> �C— � 'C��� Time In Time Out <br /> City State ZIP Cocle _....___.__ ._.__,...., <br /> Business Rep Title 0 0 AM 0 AM <br /> ° -FAbf i c-(AA or, 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Gaunt(tNhole/PTE)' <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Qlridoor <br /> R0 <br /> _ Q Inactive Q Truck <br /> Longitude 1 <br /> Q Planned Q OTR Q End Use Q Container <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 f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A 1 HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> O 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / Fn / FF <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 EXT) <br /> Q (a) 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 O 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 <br /> 11.1 PIP Pill"F <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> X � � [ 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: I �, M` p . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />