Laserfiche WebLink
Waste Tire Su, . ,..iy & Inspection Report Inspection Report Number <br /> Blil State of California <br /> CIWMB 181(New 04104) <br /> I 1 114 0 9 4 9 <br /> California Int grat d Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection� Inspection Type (Fill one) <br /> J <br /> Site Suffix: I b ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t,y '`N,," 1,t,�} Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name j <br /> Inspected By Inspector <br /> D s}-r;c:+ 3 — t� <br /> Physical Address / <br /> y -YLdtL� �tC�if r c-l. <br /> �a- Lsu.,s,c, Awe, <br /> CA <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title D O AM O AM <br /> 4L <br /> ® PM 0 3 ® PM <br /> - -- Operational Status Tire Type Business Role j Storage Type <br /> /Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 110 Active ® Passenger ®Generator ® Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive ® Truck <br /> Longitude — ® OTR Q End Use Q Container <br /> Q Planned <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 ENFORCEMENTS-TATU-S <br /> V A I HAULING AND MANIFEST Registration <br /> REQUIIRE Transport of Tires REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q O PRC <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle jl <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q -- - - -- <br /> 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 <br /> j ® In Compliance - No Violations <br /> Q Q Other: § L <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® <br /> Business Rep's Signatu Phone umber Inspector's Signature Phone Number <br /> - - - — - 62081 <br /> INSTRUCTIONS ON BACK ! Correct.* Incorrect ; E XIA M 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L A ® ■ <br />