Laserfiche WebLink
_4 _2� .. .... <br /> ----------- ....... <br /> Waste Tire Sui vey & Inspection Report ' Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) 1143522 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> !Business Profile 'Inspection Details <br /> TPID- inspection Type (Fill one) <br /> L 9 L4 C <br /> Site Suffix: C le Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L-AA CA �_3 6 Inspection Date 7 <br /> Time In Time Out <br /> Business Rep Title OAM 0 AM <br /> I D ® PM ® PM <br /> - Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) <br /> '[I that that apply) <br /> GZ 0 0 Active (0 Passenger Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 0 inactive Truck 0 Hauler 0 Indoor <br /> Longitude0 Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 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 of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> -F 1 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> OHO 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 m <br /> M M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 <br /> Inspection Form Included: O� <br /> 4-t SCO '9 0? <br /> .0 1 - 6 5--W-7 <br /> Comments Included: 0! - I <br /> Busine sRep's Signature Phone Number t gnature -- Phone Number <br /> 62081 <br /> IST UCTIO S <br /> ' Correct:* incorrect: <br /> INSTRUCTIONS ON BA i lei II <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />