Laserfiche WebLink
Waste Tire Su%y & Inspection Reportenspection Report Number ■ <br /> ® <br /> U <br /> StateCIWMO 181(New Survey Form - Page 1 I - 1 0 2 5 8 9 I <br /> CIWMB 181(New 04104) S U y g - - - - - <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> i'Inspection Details <br /> EL <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: r O Routine Q Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: r' ! ;f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Tom. Inspected By Inspector <br /> Physical Address <br /> i /— <br /> Street '- Inspection Date o (� E3E <br /> l'y <br /> - State LIP Code Time In f Time Out <br /> O AM <br /> Business Rep Title <br /> I O AM 7 'OfT 0 <br /> PM � � 0PM <br /> - <br /> t Operational Status Tire Type Business Role Storage Type <br /> if,YsCount(tNI`ole/PTLD <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> Q Active Q Passenger O Generator Q Outdoor <br /> ' u LE�S Latitude C O Closed 0AlteredQ Hauler Q Indoor <br /> . � . <br /> ,� �-� <br /> C7 <br /> T.SSS O O Inactive Q Truck <br /> Longitude - �� Q Planned Q OTR Q End-Use Q Container <br /> e s Type (Fill all tirai apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> g 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 FacilityENFORCEMENT STATUS _ <br /> - - <br /> V A HAULING AND MANIFEST REQUIREMENTS —..— Q Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 00 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> (DO 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q � 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations <br /> O I O Other: § - <br /> Comments <br /> Inspection Form Included: O' <br /> Comments Included: Q,Business Rep's Signature Phone Number Inspector's signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X24���� r , 1 =.„ <br /> PY P <br /> Yellow Co y,LEA <br /> ® White Copy:CIWMB <br /> operator Pink Cop <br />