Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Sulay & Inspection Repor __ <br /> ® <br /> wo <br /> State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 , l _ 0 U_..(3 8__0_2. 4 <br /> California Integrated Waste Management Board _ BLUE OR BLACK,INK PEN <br /> Part A-Surve ,ro I'll <br /> 10115" + <br /> RE <br />+ TPID / - Inspection Type (Fill one) <br /> Z <br /> Site Suffix: I / Q Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: < ., ,.r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address (.. <br /> Street Inspection Date r.7 '> <br /> <� <br /> - `-- Time Out <br /> State `ZIP Cocle Time In _._.. <br /> Business Rep Title n AM <br /> 0 PM � .� ' 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Tire Count,,(W, > I t <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - F D Q Planned Q OTR <br /> Q End-Use (-] Container <br /> Business Type (Fill all that applyr ' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q 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 Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS -_—_ Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q 1 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 1 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m <br /> Q 1 Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q ! Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 1 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 1 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments - - <br /> -� <br /> Inspection Form Included: <br /> Comments Included: Inspector' Si nature Phone Number <br /> usu -ss Rep's Signature Phone Number p 9 s . .. ..."- <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X J s I P <br /> - - - ■ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />