Laserfiche WebLink
t <br /> ■ ` _. Waste Tire -irvey & Inspection Rep-,,t Inspection Report Number ■ <br /> State of California <br /> CIWMB 181 California Integrated Wast(New <br /> Management Board Survey Form - Page 1 Il - 1140946 <br /> ,rt A-Survey— _ -_ BLUE OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> ti PID- Inspection Type (Fill one) <br /> Site Suffix: 3 - G f Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local v If Referral,choose referral type(Fill one) <br /> Identifier: __Y,'"7tG}hJ �l1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> A �A�I�er _ <br /> Physical Address <br /> lel C)�� E - G�;�►�f-ems �t v --------- <br /> Inspection Date <br /> � �.(`�1'1cA `5f � Time In 1 Time Outi <br /> Business Rep `{ Title O AM O AM <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 ®Generator 0 Outdoor <br /> ® Closed 0 Altered <br /> GPS Latitude LoHa er ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR Use 0 Container <br /> Business 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 ®Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V1 A I HAULING AND MANIFEST REQUIREMENTS <br /> 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 /> 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/CIWMB Enforcement <br /> 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities I <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> 61 <br /> Inspection Form Included: 01 <br /> Comments Included: ® —r (L .ICU-_I-v- ( eCC4I --— - ------- - - -- r�0 'YL� 'YL 7) <br /> Business Rep's Signat re Phone Number _40s I ature Phone Number <br /> INSTRUCTIONS ON BACK Correct Incorrect X 62081 <br /> � � ! � 13 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />