Laserfiche WebLink
Waste Tire Su ky & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181(New Survey Form - Page 1 I 1 - 1140963 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- / � � � a � j _ O ' Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local - � J If Referral,choose referral type(Fill one) <br /> Identifier: fy� -- , �J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> OIA(-d)dress <br /> Physicm�L�/ <br /> � � - / 0 14 130,A4 I., <br /> ao� v <br /> Inspection Date / I / 0 <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> j j O I o� T S ®PM V ® PM <br /> Operational Status Tire Type Business Role F. Storage Type <br /> Tire Count (Whole/PTE) 1(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active ® Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o ®Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _... <br /> --- .:_ - <br /> ;HAULING AND MANIFEST REQUIREMENTS <br /> ----- -- -- 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 /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <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 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 I <br /> -- - I � - C71•-'- - �^-`•c.- C:�t-�J-� C.�.-''may( 7�[�t� ��C�N <br /> - <br /> Inspection Form Included: 0 ` <br /> Comments Included: - - -- <br /> ® Business Rep's Signature L3 <br /> Phone Number spector's re Ph ne Number <br /> - --- - -- _ <br /> INSTRUCTIONS ON BACK : Correct: Incorrect: X X km P L � � 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />