Laserfiche WebLink
® Waste Tire Sul dey & Inspection Report Inspection Report Number <br /> State of California <br /> if CaliforniaCIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1143846 <br /> ornia 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: $ ( v Routine Q Re-inspection Q Referral Q Observation <br /> Local )sayIf Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 5 r 10 ' /46V Atmel <br /> M '7533 Inspection Date <br /> Time In Time Out <br /> Business Rep Title M 0 AM <br /> �PM 2 ® PM <br /> - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r S Active Q Passenger B Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ® 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 •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 A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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/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 In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments O %1 <br /> Ll:c, s oY czwc&e-n - <br /> Inspection Form Included: QI ^� <br /> Comments Included: Q - - -=- � — �ry�— <br /> Bus' ss Rep' nature _ Phone NumberI sp cto s ' nature Phone Number <br /> - — - - <br /> INSTRUCTIONS ON BACK C ect:� incorrect: �/i E A E i 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink opy:L ® ■ <br />