Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
Waste Tire Su. ,y & Inspactlon Report ,- ,State Inspection f/R�ieport}}'l�Number <br /> CIWM 181(California Survey Form - Page 1 V V O Y <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Lnspection Details J <br /> TPID- � � 'S � _ � � Inspection Type (Fill one) <br /> Site Suffix: * Routine Q Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP O CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name - - - - - - - <br /> Inspected By Inspector <br /> Physical Address <br /> 4' 77 8 5 woa � <br /> Inspection Date� f5�\ X753 Time In v Time Out <br /> Business Rep Title O AM O AM <br /> 1 O 0 PM O PM <br /> o.N. ' . �-- -- - -- - - - - - <br /> --- - - - <br /> -Operational Status, Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) CJ <br /> ii 0 Active Q Passenger 0 Generator Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive ®Truck <br /> Longitude - O Planned Q OTR �0 End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer 0 Auto Repair • Trucking Fleet Q Government 0 Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br /> 'i Q Notice Of Violation Q Extension <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or F_XT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O 0 Other: § <br /> Comments <br /> NN -o-r two Vs - <br /> ��t,lt�. w��`.��`r`7 '���o,�z.�s ^o� _ _all` w_-•�"- �''�- �� �• <br /> Inspection Form Included: QI <br /> Comments Included: 0, - - - -- - - <br /> usiness Rep's Signat a Phone Number I or's a Phone Number <br /> INSTRUCTIONS ON BACK r CorrectL Incorrect 62081 <br /> FL- - -- � X E I 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />