Laserfiche WebLink
Inspection Report Number <br /> y-_. Waste Tire Suoy & Inspection Report _ P - - E <br /> :k . - <br /> "�'�;.... State of California 3 l'j <br /> R&w6 CIWMB181(New 04/04) Survey Form - Page 1 -. <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A Surve rL <br /> I Bt15tt1S ;I�rd#►le', <br /> l <br /> �• _ ' Inspection Type (Fill one) <br /> TPID- <br /> jj � (� � Observation <br /> Site <br /> Site Suffix: Routine Q Re-inspection Q Referral Q <br /> If Referral,choose referral type(Fill one) <br /> LocalI Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Identifier: : �7i , <br /> A !/1 , t •in tt - - -- -- -- <br /> Business or Facility Name ) t✓ Inspected By Inspector <br /> Physical Address <br /> Street J Inspection Date I (� <br /> �f <br /> L_ _ �_- G 1 Vl ✓U __ Time In Time Out <br /> City _ -- State ZIP Code — - AM Q AM <br /> Business Rep Title . <br /> 0 PM _._ O PM <br /> Fill all apply)! Fill all that apply) f (Fill all that y apply): <br /> Operational Status Tire T e Business Role Storage Type <br /> (Fill one only) ( pp Y) ( p <br /> I TI: Q Passenger Q Generator Q Outdoor <br /> d Q Active <br /> d Closed Q Altered <br /> _ Q Hauler Q Indoor <br /> GP$ Latitude F7 _ - <br /> '0 Q Inactive Q Truck <br /> i Q Planned Q OTR Q End Use Q Container <br /> Longitude - }} <br /> I 4 . <br /> i 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> trEM and Transport of T7days <br /> Q Notice Of Violation Q Extension <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Regis p <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC 42956 Registration/Decal <br /> in Vehicle <br /> OHO § 1 <br /> Q 1 Q 14 CCR§ 18459 Responsible Entities Complying with ManifestDate <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs withQ Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 Q Q Q Referred l CIWMB Enforcement <br /> 14 CCR§ 18460.2-Manifest System Requirements for Register <br /> Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§ 18461 -Manifest System q - <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q � <br /> QIQOther: § - - - <br /> __ __----------- ----- _. <br /> [CommentsI-n�� �; Cf" �.E j T �Gl - tf� ti Y <br /> jInspection Form Included: Q <br /> Comments Included: Q Business Rep's Signature Phone Number Inspect/or's Signature Phone Number <br /> - _ 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X 1 q + �' LiEt 1 r Ig <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> ■ ® ■ <br />