Laserfiche WebLink
- <br /> ■ ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> r�= State of California 11 - 1144023 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey <br /> _ <br /> cess Profile Inspection Details <br /> TPID- � - Inspection Type (Fill one) <br /> Site Suffix: ` �J p2 Q ® I I® Routine Q Re-inspection Q Referral Q Observation <br /> Local / (� If Referral,choose referral type(Fill one) <br /> Identifier: ,ln C� VI� (rCGyl� I C✓I — -- Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> Cance <br /> Physical Add ess <br /> (/� ��j-,�f,� Inspection Date � <br /> ��` , `-""`�'�'� Time In Time Out <br /> Business Rep Title AM <br /> 0 AM <br /> 0 PM ( 0 PM <br /> _ Operational Status Tire Type BStorage Type <br /> usiness Role <br /> j(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> Q Active Q Passenger �, Q Generator Q Outdoor <br /> ® Closed Q Altered i <br /> GPS Latitude tt� Q Hauler �I Q Indoor <br /> O <br /> Q Inactive Q Truck i {' <br /> II iLongitude - Q Planned Q OTR Q End-Use Q Container <br /> '-•siness Type (Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> (� Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 16 Other r ��j� V1? <br /> ealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Part B- Inspection of Waste Tire D <br /> - <br /> V-1 A I 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. j Compliance Deadline <br /> I <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements ( Date <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 ®In Compliance No Violations <br /> I <br /> Q Q Other: § -- <br /> Comments <br /> jlnspection Form Included: <br /> s Ski-natt-ure, tiature Comments Included: SignaBusin ss Rep' g Phone Number I pct Phv62081 <br /> 213 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: '� E X AT <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ®. <br /> ■ <br />