Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
® Waste Tire Suy & Inspection Reportspection Report Number IN <br /> Gu State of California A41 <br /> 109 CIWMB 181(New 04/04) <br /> Survey Form - Page 1 <br /> Management Board - s <br /> California Integrated Waste Manage <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> r <br /> BusinessInspection Details <br /> 'Pt`�fi,.�w r' _ <br /> IO Routine ORe-inspection OReferral OObservationTPID- Inspection Type (Fill one) <br /> Site Suffi <br /> Local - If 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 /> F ` ( I - <br /> 1 - <br /> `Physical Address � �' ' •' <br /> Street �. .�. <br /> Inspection Date <br /> Ti In Time Out <br /> C'itb� State Zlf Code _ _.. <br /> Business Rep Title - O AM I O AM <br /> O PM 0 PM <br /> ✓ rt. t <br /> - <br /> Sit( <br /> Operational Status ( enypeBUaornge Type <br /> (Foneonly) (Fill lapply) ( II all that apply) Fill althat apply) <br /> Tire Count(Whole/PTE) ' <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Latitude Q Hauler Q Indoor <br /> GPS ---- -- Q Inactive Q Truck <br /> io <br /> Longitude - i�� iI <br /> N^Q-^ x Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> 1 <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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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 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 Q In Compliance - No Violations <br /> 0 0 - - <br /> Other: § <br /> Commentsr <br /> 1 I " r <br /> � <br /> AGI �� trtii�. P1 j�.o I� .6,/ � �Q <br /> rr' <br /> Inspection Form Included: Q' <br /> Comments Included: <br /> QI Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X E X A "N�, 1. I - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />