Laserfiche WebLink
Inspection Re Waste Tire Suy & Inspection Report, p port Number <br /> Ins <br /> , .. <br /> State B California 11 - 1086959 <br /> f Survey Form - Page 1 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey <br /> BLUE OR BLACK <br /> Business Profile Inspection Details <br /> TPID- r _ Inspection Type (Fill one) <br /> Site Suffix � L . J I " LlJ (C) Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: L, ' ` �(_ L. ' 4( 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address`s' <br /> Street <br /> c [ Inspection Date <br /> city - Time In Time Out <br /> tarty State .ZIP Coc _ _ <br />' Business Rep. Title O AM O AM <br /> T O PM - 0 PM <br /> 11C"C...'r( �tl r <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE)" L <br /> r Active 0 Passenger Q) Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude , 0 Hauler 0 Indoor <br /> ' 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business"ype (Fds a=i shat a"fn,..ly),- _ <br /> Q New Tire Dealer 0 Auto Repair, 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 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 ofWaste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A71 HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 1 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 O <br /> 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 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ! f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> tksirfess Rep's Signature Phone Number Inspectgr's Signature Phone Number <br /> —"' <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X /I- I,/ E X A 4Ti 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />