Laserfiche WebLink
°== Waste Tire Su, jey & Inspection Report Inspection Report Number ■ <br /> 1�G State of California I 1143826 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey---- - -- - -- -- -- - <br /> Business Profile Inspection Details <br /> TPID- -, Inspection Type (Fill one) <br /> Site Suffix: 61 p� Routine Q Re-inspection Q Referral Q Observation <br /> Local �' `^ If Referral,choose referral type(Fill one) <br /> Identifier:- l l l --�UtA� (1-MAIL — Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Add s / l <br /> ._r� Inspection Date } 1 <br /> /�� q'�7� l <br /> Time In Time Out <br /> Business Rep Title � '? � o PM; -y� j 0 AM <br /> _J/� V WPM <br /> -00 <br /> V ------ `' --- - - -- -- Operational Status Tire Type Business Role to <br /> Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f (J <br /> ®Active ®Passenger ® Generator ®Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 to Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> V I 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 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 In Compliance - No Violations <br /> Q Q Other: § — <br /> Comments j�� \ , Jcr <br /> 1�-JJs— _Oj <br /> Cr( cef✓V <br /> ,Inspectio�nForrn Included:Coments Included: Q, -- - - <br /> � ;Business Rep's Signature Phone Number *kA <br /> e Phone Number <br /> .------ 62081 <br /> INSTRUCTIONS ON BACK Correct_ Incorrect: ,} V: 112 31 <br /> ■ White Copy:CIWMB Yellow Copy:Operator ® 0 <br />