Laserfiche WebLink
IF <br /> Inorf Number <br /> F- Waste Tire Suy & Inspection Report __--s p-ection Report <br /> State of California _a } �j !t I ! <br /> aim CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board - z <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Bus�)ti5'Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix6)1 sl (� / Routine Q Re inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: j yj ;(,7 f r tr , ( Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i f_.'Y Inspected By Inspector <br /> y t,t EllJ <br /> Physical Address <br /> Street )+� Dateection Ins <br /> p <br /> City i State- ZIP Cade Time In Time Out <br /> Business Rep Title ^^_�ryu1 0 AM 0 AM <br /> 0 P �. 0 P <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 /> Active Q Passenger Q Generator Q Outdoor <br /> LL( I 0 Q Closed Q Altered <br /> LatitudeE I I �,,H <br /> GPS L� _l__ .._ Q Hauler Q indoor <br /> _ O Q Inactive Q Truck <br /> Longitude — <br /> FT7 <br /> � , Q Planned Q OTR <br /> (Frll jM� Q End-Use Q Container <br /> -1111-- iii -. .,,r. <br /> Business Type 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 Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredders Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> QQ PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> V A HAULING AND MANIFEST REQUIREMENTS <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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O -- -- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i CIWMB Enforcement <br /> Q Q 1 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 /> Q Q Other: § -- _- <br /> Comments / r <br /> Lw /i7 xl t �" r �t_ t 7H'�%i !� I.,,�,{:t. 1: `� r �I 1["t�It i.,-Y', TL. 1,•�,I <br /> V <br /> @ 4?VUIJ!" 1 1 _ " 1 v".t. t (' Vlir i/ r ' (!�''Cc f` > (It r�i/L f <br /> Inspection Form included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector'11 s Signature Phone Number <br /> � 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ; �/ � � I I M �L <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />