Laserfiche WebLink
Waste Tire SAW & Inspection ReporAlkispection Report Number <br /> State of California <br /> Qat CIWMB 181(New <br /> Mana a) Surve`, Form - Page 1 ( 1 - 1 0 1 3 5 3 8 <br /> Califf:rnia Integrated Waste Management Board J Page <br /> ".- Survey BLUE OR BLACK INK_ PEN <br /> nspection Details <br /> TPID- � � � �Fq <br /> � � IType (Fill one) <br /> Site Suffix: ELdnspection Q Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 41� �J `.f ,� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> I I Fr c,.._., __ _--=� - -- I <br /> Street <br /> � Inspection Date�� <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> O PM O PM <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(WholelPTE, <br /> (&Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> I GPS Latitude � • Q Hauler Q Indoor 41 <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <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 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 Notice Of Violation Q Extension <br /> Q Q 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 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> (a 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 <br /> b_,[ 2-7. 1 V5;7_/1� . l� -3 2- / c? <br /> 2,1o52_; 4T_ 7—tf7 22_3 'z - ,b �r <br /> > <br /> Inspection Form Inc b e& <br /> Comments included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature <br /> ' ad.,1T � f <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � � 7C A , F L 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />