Laserfiche WebLink
Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CIWMB181(New04104) Survey Form - Page 1 12 - 1079489 <br /> California Integrated Waste Management Board BLUE OR BLACK INKPEN <br /> Part A--Survey <br /> Business Profile — <br /> Inspection Details <br /> TPID- inspection Type (Fill one) <br /> Site Suffix: 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> If Referral,choose referral type(Fill one) <br /> Local So"n llyxq I 1 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Identifier: 0 CHP <br /> Business or Facility Name Inspected By Inspector <br /> M LS ?_ G) 01 <br /> Physical Address &0 <br /> Inspection Date a C;_ <br /> <�A� 0 C�&0 CA Cnals Time In Time Out <br /> Business Rep Title C) AM <br /> 0 APM M 0 PM <br /> 0 Operational Status Tire Type Business Role Storage Type <br /> cr— (Fill all that�_3 (Fill one only) (Fill all that apply) (Fill all that apply) at apply) <br /> Tire Count (Whole/PTE) 6 Active ® Passenger 0 Generator 0 Outdoor <br /> GPS Latitude 0 0 Closed 0 Altered 0 Hauler 0 Indoor <br /> G 0 � 0 inactive 0 Truck 0 End-Use Container <br /> Longitude 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader Q 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 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility _ENFORCEMENT STATUS <br /> V I- A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> _r 0 0 P <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 * 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 (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ....... <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 /> C, <br /> Comments 0 <br /> (VI ''I-r\ o jAm Sw <br /> Inspection Form Included: 0 <br /> Comments Included: * <br /> Busin S uie MeN Number --Inspect- s ignature one Number <br /> 62081 <br /> lie 2 3 <br /> BACK 'Al --- <br /> INSTRUCTIONS ON Correct:0 incorrect: _ , XAM <br /> ■ White Copy:CIWMB Yellow Copy:operator Pink Copy: <br />