Laserfiche WebLink
Waste Tire Suy & Inspection Report lnspection Report Number <br /> -- - - <br /> -� ''^+. State of California <br /> _ = CIWMB181(New 04/04) Survey Form - Page 1 i i i �_ <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Inspection Details <br /> TPID- 1-2 l o Inspection Type (Fill one) <br /> Site Suffix: `//� 1� /o� 6_ ® Routine Q Re-inspection Q Referral Q Observation <br /> Local `` i fr / If Referral,choose referral type(Fill one) <br /> Identifier— - /7 '. `_�=`r. [c.� ,'} f- � -''f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> - / r ,� <br /> Physical Address / ? !/�r f/A <br /> Street` I / L C� <br /> nspection Date <br /> F—H-) <br /> � ff/� , 7 <br /> -----State State ZIP Cade Time InTime Out_ <br /> Business Rep Title O AM . F ® AM <br /> � � • ��._` O PM I QPM <br /> Operational Status Tire Type Business RoleStorage Type <br /> (Fill one only) (Pili all that apply) (Fill all that apply) (-ill all that apply) <br /> Tire Count(Whole/PTE) f "' <br /> ® Active Q Passenger Q Generator Q Outdoor <br /> Latitude ��...` -_ Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> GPS k <br /> 010Inactve c <br /> Longitude - , Q Planned Q OTR Q End Use Q Container <br /> Business Type (Fdi all that apply) <br /> Q New Tire Dealer Q Auto Repan- Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I q _[HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q I 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 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 C §18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q m / mCR / [T] <br /> Q Q 114 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q Q 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 1 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 Q In Compliance - No Violations <br /> I <br /> Q Q (Other: § _ <br /> Commentsr' <br /> v`J� <br /> Inspection Form Included: 0.- <br /> Comments Included: Q <br /> Business Rep's Signature Phone hlts9atber Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />