Laserfiche WebLink
1 <br /> i.: Waste Tire Survey & Inspection Repos L Inspection Report Number <br /> State of California I .L 1143742 <br /> CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> t A--Survey —_ _-_ __ BLUE OR BLACK INK PEN_ <br /> iiness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` u e l 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local \\ If Referral,choose referral type(Fill one) <br /> Identifier: SOY\ .X�'�LC 111` C�l.� 10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name U Inspected By Inspector <br /> Irl (I c _ I ` ) <br /> Physical Address l 0 ( h` {� /�yn� <br /> Inspection Date 1 <br /> ( Time In Time Out <br /> Business Rep Title AM ®AM <br /> O PM f �✓ O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered 4110� <br /> GPS Latitude 0 Hauler 0 indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container— — _— <br /> ausiness 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 /> U Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other t je <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> 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 / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 rJ <br /> Comments Included: f� <br /> Business R Signatu ""one Number I *ME ure Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: > �df 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />