Laserfiche WebLink
Waste Tire Su� .ey & Inspection Repor.. Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1144025 <br /> California Integrated Waste Management Board <br /> A-Survey - -_ _ BLUE OR BLACK INK PEN <br /> mess Profile Inspection Details - <br /> TPID- l fi Inspection Type (Fill one) <br /> Site Suffix: 13 1 .Routine Q Re-inspection Q Referral Q Observation <br /> Local \ lN If Referral,choose referral type(Fill one) <br /> Identifier: � J [-�l J, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Busine s or Facility Name Inspected By Inspector <br /> Physical Address <br /> 22 Inspection Date <br /> G7`��� -A 716 Time In Time Out <br /> BusAes$Rep Title 22 �/ O AM �•� AM <br /> h^uko J 6 O PM lJ ® PM <br /> (leCAAC-LYA CC, <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 01 Q Active ® Passenger S Generator Q Outdoor <br /> D ® Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> D Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New 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 ® Other v ITL4� 1 Q;r v( <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS I 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 I 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 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 /> Q Q Other: § <br /> Comments <br /> wmc <br /> Inspection Form Included: Q�, j� <br /> Comments Included: ®II (��(J/ --(, 2 0 �P 2Q�` 73 <br /> 2,0 <br /> BBB -- — - - <br /> usiness Rep's Signature Phone umbers Iop or's S n ture Phone Number <br /> —— ; 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect. X ! A MI <br /> � L �; 1 �' 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />