Laserfiche WebLink
section Report Number <br /> y Waste Tire Su�y & Inspection ReportQ►� p p -_ � <br /> aa1i� G 31 <br /> State of California +i § <br /> `" 1 CIWMB181(New04/04) Survey Form - Page 1 i - ' l <br /> California Integrated Waste Management Board e <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile "a;�1t5pS'C I r1 PrtS1�S' ,Iq,': y .vimI �.4/aw.�.��.�,�, �.4�.�i r of ✓, M., <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix L/ �� f U 1�� j (4 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> I _ <br /> Physical Address `) 1 ! <br /> 'r J <br /> Street <br /> Inspection DateEzE/ EE <br /> City State ZIP Code Time In Time Out <br /> � <br /> Business Rep Title O AM 0 AM <br /> [I] <br /> 0 PM 0 PM <br /> G p � a tom__-__.._�._.I _ •-- -- <br /> ! Iii j S�v.-w'.- ...E '� I.1 1(..•.-.1 <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 /> Active Q Passenger Q Generator Q Outdoor <br /> t _ D Q Closed Q Altered <br /> GPS Latitude QQ ,LII-= Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude <br /> Q End-Use Q_ I 177-T 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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> 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 Q In Compliance - No Violations <br /> Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: Q - - - _-- -- -- <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -- _� 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X t A � �'j �i E I i 1 j �I�I <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />