Laserfiche WebLink
Waste Tire Su. .;y & Inspection Report iInspection Report Number <br /> irl State of California <br /> CIWMB 181(New Survey Form - Page 1 I 1 - 1140708 <br /> California Integrated Wastt Manage <br /> Waste Management Board <br /> Part A- Survey___ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 0 6 6 7 d Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 7 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 <br /> Inspected By Inspector <br /> 1.3��D"7�e <br /> Physical Address 3 7 <br /> J/S-v _ �lz�u L2ce'er <br /> Inspection Date () <br /> 7 Time In Time Out <br /> Business Rep Title / •AM •AM <br /> O <br /> (" 0 PM QPM <br /> - <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) f 7 0 <br /> 0 Active • Passenger Generator ® Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude End-Use <br /> g - - -. -- - 0 Planned-- -- 0 OTR - 0 - 0 Container <br /> I, <br /> Business Type (Fill all that apply) <br /> • New Tire Dealer • Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body • 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 Aj HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <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 Fp / m / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 (9 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: Di <br /> Comments Included: 0 - ---- --- - <br /> Business R ignature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK ! Correct: Incorrect: �( � E Xf rAI 1 Z 3 62os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co y:L <br />