Laserfiche WebLink
Waste Tire Survey & Inspection Repo, c Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il 1140774 <br /> California Integrated Waste Management Board <br /> A- Survey BLUE OR BLACK INK PEN <br /> I.ness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I y 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 Educational Visit 0 Other <br /> 0 CHP 0 CIWMB 0 Complaint <br /> Business or Facility Name Inspected By Inspector <br /> C,le,t\\ � c <br /> Physical Address 10 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title tt 0 AM 0 AM <br /> PM 'ey C) OPM <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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 4p Closed 0 Altered N14 <br /> GPS Latitude SIA 0 Hauler 0 indoor <br /> Longitude 0 0 inactive 0 Truck 0 End-Use 0 Container <br /> 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 /> 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 Al 1A <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <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 /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> I 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 /> 0 0 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 I 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� <br /> Comments Included- 0. - ___- - <br /> Business Rep s S tgnaturell Phone Number or' ig ure — Phone Number. <br /> ::�� —V 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X Ak' gA E 1 1112131 <br /> MWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />