Laserfiche WebLink
Waste Tire Su & Inspection Repor spection Report Number <br /> -7ID�3,S8 State of California - r.. - ■ <br /> CIWMB 181(New 04104) S ey Form - gage 1 �` a U <br /> California Integrated Waste Management Board - <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Busttless Profile ' Irrspectto i Details <br /> J <br /> T?ID- _ p Inspection Type (Fill one) <br /> Site Suffix: + f <br /> Q Routine Q Re-inspection Q Referral Q Observation <br /> Local V _i If Referral,choose referral type(Fill one) <br /> Identifier: <br /> F;.�:�' _ � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> i <br /> Street <br /> Inspection Date <br /> Business Rep _ __..—__ —..-- S, Time G"ocPe Time In Time Out <br /> Title _.. 0 AM , EL- <br /> Q AM <br /> QPM0PM <br /> Operational St sa utut Tire Type O <br /> ole Storage <br /> Type e <br /> (Fill one only) (Fill all that apply)! (Fillall that app Y) ( alapply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> _ _ M ` ar__7­7 <br /> C-i Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive Q Truck I <br /> Longitude Q Planned Q OTR Q End Use Q Container <br /> II <br /> trr I <br /> Bustttess'Type (#il(all`that"apoly) ' <br /> -=--::: <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 /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q § 9 P iO Q <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 Q14 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 Q In Compliance - No Violations <br /> Q I Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Include rt: Q ' 7 fir, f: <br /> it" thf <br /> Business Rep;;.Signature —- Phone Number IrSpe ,. �E .:. Phone Number <br /> INSTRUCTIONS ON BACK Correct: incorrect: X lip , 4 (� � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> m <br />