Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB181(Now 04104) Survey Form - Page 1 1 9 10 2 0 7 4 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP I) CIWMB 0 Complaint 0 Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical tAddress <br /> Inspection Date 0 0-5 <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' 0 P 0 P <br /> r <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Pili one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 40 Passenger 0 Generator i Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer ()Auto Repair Q Trucking Fleet 0 Government 0 Retreader 0 Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Hauler 0 Agriculture 0 Shredder 0 Other 61f7 (khC'4y <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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle M <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirementste 014 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Rei7ulted trNOV;Qi 7 <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIMetngrft <br /> 0 0 14 CCR§18461 -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 <br /> Ih Cp> ptl$tioe, Itisti� <br /> '0 0Other: § <br /> Comments � d'DV1�C-k c.�/>%Q <br /> /��n1►��t � ' Ir <br /> Ile- <br /> h /Y� �V�Via e� q/ 5 c-dwlct r� �Jrs 7�Mq� _ <br /> + v <br /> -inspection Form Included: 0 9s'3 -765$ <br /> Comments Included:Q <br /> Business Rep's Signature Phone Number In or ature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: XX & tV! E I t s2oa1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />