Laserfiche WebLink
inspection Report port Number <br /> -° Waste Tire S ey & Inspection Repoi p <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 . . _ <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A SurVe « a <br /> Inse "r <br /> petfttf �. <br /> 11 <br /> ,. < .Inspection Type (Fill one) <br /> TPID <br /> Q Re inspection Q Referral QObservation <br /> Site Suffix: Q Routine <br /> Local fr f. If Referral,choose referral type(Fill one) <br /> Identifier: f i t f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I Business or Facility Name Inspected By Inspector <br /> Physical Address _ <br /> Street t, Inspection Date <br /> I' ! a ( r' <br /> I_ �' Time In_ Time Out <br /> _ <br /> City State ZIP Code <br /> ` Title O AM : O AM <br /> Business Rep <br /> - FT QPNI m QPM <br /> f <br /> r Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> i rt ( Business Role Storage Type <br /> L f t to = <br /> „ Operational Status Tire Type <br /> l/ moiw <br /> ® Active Q Passenger a Generator Q Outdoor <br /> Q Closed Q Altered <br /> Gtude �Q , —� Q Hauler Q Indoor <br /> PS Lati <br /> C Q Inactive Q Truck <br /> Longitude - FT 17 ,� � Q Planned Q OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all khat 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 (a Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 I Q PRC§42956-Registration/Decal in Vehicle / <br /> Q I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date [1-1 / m m <br /> Q Q 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB (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 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q Other: § <br /> L �f I - <br /> Fomments }i, - Clr<: (V-11 <br /> l <br /> (I Ili(Iieov"All, tws J, <br /> .r <br /> ate <br /> = '• }� , ; ,tet •�.,: �� 1f /�.r r <br /> i <br /> r ' Ali- -----— ---- <br /> Inspection Form Included: Q <br /> Comments Included: QIns Inspector's Signature Phone Number <br /> Business Rep's Signature Phone Number p _g <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �. r _; ,r�r 1 i(W� i <br /> ■ White Copy:CIWMB <br /> Yellow Copy:Operator Pink Copy:LEA ® ■ <br />