Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> - CIWMB 181(New 04104) Survey Form - Page 1 I 1 - 1143749 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- p Inspection Type (Fill one) <br /> CJ <br /> Site Suffix: ` 0 ' f$ Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �\ - V `C��� �l _ O CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name �' Inspected By Inspector <br /> A�111Uy)�)6S a'Zo' 4�vG:> <br /> Physical Address l c) l <br /> �r Inspection Date 5 <br /> Time In Time Out <br /> Business Rep Title / V ®AM AM <br /> V 0P 0 7 OPM <br /> - - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) � <br /> 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> D ® Closed Q Altered IYIA /Y/14 <br /> Latitude <br /> GPS /4` Q Hauler Q Indoor <br /> D O Inactive Q Truck <br /> Longitude - O Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> ® 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 17 � m / M <br /> Q O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E>M <br /> O O - _- - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O 0 114 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O O Other: § t__\ <br /> Comments A t��J -1�A J �� T 1Yl 5 c 1� fTVZJttS G�1 <br /> _ ; ct' vt � ►�ej_1�s f �►_+� fc.. �11�i ,� lesrre ✓ ' c,fi a.f-'t��3 tee . + <br /> Inspection Form Included: Q <br /> I Comments Included: 0 - --- - gPinkco : <br /> Business Rep's Signature Phone Number re Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect i62081 <br /> XWhite Co CIWMB Yellow Copy:Operator ® ■ <br /> PY <br />