Laserfiche WebLink
Waste Tire Sur*y & Inspection Report Inspection Report Number. _A <br /> State B California 11 - 1108449 <br /> CIWMB 181(New <br /> Manage) Survey form - Page 1 <br /> California Integrated Waste Management Board Y J '- -----..— ---------- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> - --- - — <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / ! ) I g � A 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: 1 T;(d C i.t o"I I. C%l r r ( � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name / <br /> J 1 Inspected By Inspector <br /> Physical Address - ^J - �/L l t r y r,/T <br /> . ;e <br /> Street F <br /> Inspection Date <br /> Business Rep Title State ZIt�Cade Time In O AM Time Out / Q AM <br /> 0�--.. 0 PM � 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> :uRi! MEN <br /> Tire Count(Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> M wi 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 ( Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0: 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> r I <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 1 0 Other: §, — - — ---- - -_ -------- -.-- <br /> Comments <br /> �j -r 1 <br /> _�Pt' �.�.l �l C/-� 1 -_—_ -(�'_—��d�l� 1 V6 � V �d�'IC�1 J� `-r � (vk <br /> OC41'VI I e >'1 l t(�✓.(�� (;r h .a `i✓ ��t' yt i ` 1 /U <br /> !�(' ✓lC b C:� -`i CYl'I /l'( l j rC ��/ �l ,� � f C o <br /> Inspection Form Included: 0 <br /> Comments Included: 0' _ - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> --, <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X /;, V i A"rtl l L i L m i i i aP i 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® 0 <br />