Laserfiche WebLink
Fr <br /> ■ " <br /> Waste Tire S c Inspection Repo*141 Number <br /> BCia: .1' State of California <br /> CIWMB 181 lNew 04/04) Survey Form - Page 1 4.0105 <br /> California Integrated Waste Management.Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ;Site Suffix: 1 C� Qb 1 ,:<., <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local ✓ <br /> G C <br /> r If Referral,choose referral type(Fill one) <br /> Identifier. Gf 6I �(t r��i 7 ( Q Educational Visit Q Other <br /> 1A <br /> Business or Facility Name U Inspected By. Inspector <br /> Physical Address - JA <br /> Street <br /> CAInspection Date <br /> City Sate ZIP Code <br /> v I Time In v Time Out <br /> Business Rep Title O AM Q AM <br /> 0 PM 0 PM <br /> A( -- <br /> O erational Status Tire Type Business Role Storage Type <br /> p <br /> Tire Count (Whole/PTE) a l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger (9 Generator Outdoor <br /> O Q Closed Q Altered s <br /> GPS Latitude m • Q Hauler Indoor <br /> O Q Inactive Q:Truck <br /> Longitude - Q Planned Q:OTR Q End-Use Q:Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q.Used Tire Dealer ®Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS ___ - �I <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension 1 <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 <br /> M / m / m <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-.Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q ....--------------- ---------- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 „1 In Compliance - No Violations <br /> Q 1.0 Other: § '' <br /> Comments D ti ( .( IVI <br /> vC)rC �7v, ��{,( �� +f ';� �•�� (I,1L gJtGi <br /> /_ }}s �� ll S (✓.(� ��' �� r(1C(l,�t f7Gl , �f'Gr.! ' �C)✓� 1✓�. 0PCcll /} afn <, <br /> . <br /> I c ,Jr C) ✓�,� �' t;C t� f, C r�-- l t c:?ct c 4 <br /> v Ya <br /> Inspection Form Included: Q <br /> Comments Included: Q Business Rep's Signature Phone ne Numbe-r./ Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X) V� �' •AIM P' :L ; 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> r it <br /> . I' <br />