Laserfiche WebLink
Waste Tire Su y & Inspection Report nspection Report Number <br /> StaliSurvey Form - Page 1 �t 4 6 3 <br /> CWMB1 (New <br /> IWMB 181(New 04/04) ■ <br /> California Integrated Waste Management Board -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r,> 1 -71 (, - 0 Routine (a) Re-inspection 0 Referral 0 Observation <br /> Local �. �` If Referral,choose referral type(Fill one) <br /> Identifier: ��, 4 - j/ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J7 - r �� I` -"ter - �(�.{e <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 73 ®AM O AM <br /> QPM 0 P <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- <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O z�I <br /> Latitude 0 Closed 0 Altered <br /> GPS Q Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 0 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 /> - - - - - 0 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 /> inspection Form lncluded�'() <br /> Comments <br /> nsPeComments Included:d. 0 ,. <br /> Business Rep's Signature Phone Number Inspector's Signature_ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �, \/-I l ExTh 0Aj P 1 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />