Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California Survey Form - Page 1 1 8 - 1 0 4 8 9 7 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> .Business Profile Inspection Details <br /> TPID- { � � ^ � � � _ p � Inspection Type (Fill one) <br /> Site Suffix: r `7 Q Routine 0 Re-Inspection Q Referraf Q Observation <br /> Local — If Referral,choose referral type(Fill one) <br /> � <br /> identifier: r J" �-� 0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> I <br /> .a� f-34:, Jr l Ci l�-S' / 7 <br /> Physical Address I D �p�r•w"' ,� ,s <br /> TY; LJv <br /> Inspection Date 3 I I <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> -� 0 PM 0 PM <br /> Operational Status Tire Type ' Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r •Active • Passenger 0 Generator • Outdoor <br /> O 0 Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 0 Inactive Q Truck <br /> Longitude - O Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Deafer 0 Auto Repair Q Trucking Fleet 0 Government Q Retreader 0 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 O Hauler 0 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 �I1I <br /> Notice Of Violation ���t9n$ion <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O O. <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. + Compliance Deadline <br /> 0 j 0 i PRC§42956-Registration/Decal in Vehicle <br /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements I Date / I <br /> O O <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R9qulred for NQ1l <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Rafarrgd I CIWMB Erlikfi3�l}1�ri� r <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 <br /> O � O <br /> Other: § 11 �/� / Q�+ q 7 <br /> Comments �Rrii 7'S r' r /� 1- r © .'� 1 Ir <br /> (v ^(,r©5j1�✓1�r7 <br /> 00 <br /> Inspection Form Included: o. <br /> Comments Included: Q - <br /> 8usin Rep's Signature Phone Number Inspe s Ig a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK I CorrectV incorrect: (X(jq� E X A Ah I P I lr E;Til 2 3 <br /> . While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />