Laserfiche WebLink
Waste Tire Su. ✓ey & Inspection Report -Inspection Report Number <br /> ria State of California <br /> CIWMB 181(New 04104) <br /> I 1 - 114 3 7 5 8 <br /> California Int grat d Waste Management Board Survey Form - Page 1 <br /> Part A-Survey _ _- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � _ O I Inspection Type (Fill one) <br /> Site Suffix: 4D Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: Sqo -'�O(x, u'I n CQk.A$�_ O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> C�lo SSeM Fkf MSJ -PhysiAddress �e n Es c46 <br /> }(�321 t4 �� - <br /> &0 \V,L,/ J k Dn `(/A gs2li Inspection Date <br /> Time In Time Out <br /> Business Rep n Title S AM l U AM <br /> nAl 1� ' J Q PM l I l 0 O PM <br /> - --------- v _--.-- --- - --- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f p Active ® Passenger S Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 19 OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler 0 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 Faf m <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 /> 0 i O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 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 EXT) <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q O Other: § } ,j <br /> Comments l_(?�_P (�r 1�1� t!.1���" �O I <br /> Inspection Form Included: Q , <br /> Comments Included: I - J- <br /> Business Rep' nature Phone Number �Ins, or's Signature Phone Number <br /> - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect X �/! I ,aa, + I L 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L LA 0 <br />