Laserfiche WebLink
----- -- ---- <br /> Waste Tire Survey & Inspection Report inspection Report Number ■ <br /> State of California <br /> CIWM181(New 04/04) 1144027 <br /> I3 <br /> California Integrated Waste Management Board Survey Form - Page 1 BLUE OR BLACK INK PEN <br /> t A- Survey__ - -: --- - - ___ <br /> ,siness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 9 <br /> Inspection Date <br /> CA Time In AM Time Out <br /> Business Rep Title 1 '2 : <br /> 0 AM <br /> 3 0 PM PM <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 /> Tire Count (Whole/PTE) 0 Outdoor <br /> 0 Active 0 Passenger Generator <br /> GPS —Latitude 0 0 Closed 0 Altered 0 Hauler 0 Ind'y/A <br /> 0 0 inactive 4&Truck 0 End Use 0 container <br /> Longitude 0 Planned 0 OTR <br /> ,siness Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 1 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> 1 <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators No Violations <br /> 0 � 0 0 In Compliance <br /> 0 Other: § <br /> Comments <br /> — <br /> nspection Form Included: 0 <br /> 4 <br /> Comments Included: p o s ignature Phone Number <br /> I <br /> S &P L <br /> Phone Number <br /> 6�1_1 S s gnature <br /> 62081 <br /> INSTRUCTIONS ON BA K Correct:* Incorrect: X X A M I-IF1 I 112 <br /> ■ White Copy:ClW MB Yellow Copy:Operator Pink Copy:LEA <br />