Laserfiche WebLink
aWaste Tire Sur*y & Inspection ReportleInspection Report Number <br /> StateCalifornia Survey Form Page 1 C 3 - 1 0 0 0..0 Z 0 <br /> CIWMB 181(New 04/04) <br /> California IntegratededWaste Management Board _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profit <br /> SteDSuffix: Inspection <br /> Type (Fill one) <br /> Q Q Re-inspection Q Referral Q Observation <br /> Local 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 <br /> Inspected B <br /> P y Inspector <br /> ;Physical Address � — __ ' <br /> Street / / <br /> Inspection Date !__-_.l__I <br /> Gi"� State ZtP Code Time In Time Out. <br /> Business Rep Title � M <br /> ' 0PM � ' l _.� 0 AM <br /> ® PM <br /> Operational Status Tire Type ype Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply)'. <br /> w°i� li�itiPiga�a f!'f"ilr 4� ,i. �(i�pra� <br /> Q Active Q Passenger Q Generator Q outdoor <br /> 0 Q Closed oseQ Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> _ - <br /> 4siness Type (Fill all that apply), <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q GovernmentQ 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 /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q 1 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 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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 Requirementslfor Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: § Q In Compliance - No Violations <br /> Comments <br /> 4 <br /> Inspection Form Included QI t,tztft �o,.;..„ r a� <br /> Comments Included: Q,Business Rep's Signature Phone Number <br /> Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:41 Incorrect: X X A N;°P Ir Cm 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />