Laserfiche WebLink
Waste Tire Sufy & Inspection Report' <br /> ispection Report Number <br /> State of California <br /> CIWMB181 <br /> Waste <br /> Survey Form - Page 1 $ - <br /> California Integrated Waste Management Board � - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Mmi ft, Inspection Details <br /> TPID- In31 ?1--ql 4 � 3F&Ispection Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> -pe -- <br /> — 1 r <br /> Ph y sical Address � 9 <br /> Street <br /> / l Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role torage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) ( <br /> Tire Count (Whole/PT Fill all that apply) <br /> (Z)Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that appY <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 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 (a) 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 A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of Violation 0 Extension <br /> 0 0 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 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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> n, t <br /> .j <br /> Inspection Form Included: 0 <br /> Comments Included: 0 � <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X E XIA l p I L I El f 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />