Laserfiche WebLink
., Waste Tire S' `.y & Inspection Report pection Report Number <br /> 90i State of California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 I 1 - 114116 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile` Inspection Details <br /> TPID- I Inspection Type (Fill one) } <br /> Site Suffix: L { O Routine (a Re-inspection Q Referral Q Observation <br /> Local � C - / If Referral,choose referral type(Fill one) <br /> Identifier: �GIV 1 � (J !y 1 ` �11 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> L . <br /> .....__`_��.,.._ ....�....ire.--_......._ _ (�L _ ....._..._............._._._.�..._T.__._..._.....1 <br /> �— <br /> / C <br /> � Inspection <br /> Street Date <br /> ` 1 ry C5�G51' L <br /> City State ZIP Code Time In I <br /> E <br /> Time Out <br /> Business Rep Title _ O AM I ] i O AM <br /> • OPM _ ' 0 P <br /> / o <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/ E) <br /> . . <br /> O Active Q Passenger Q Generator 0Outdogr <br /> O Q Closed Q Altered <br /> GPS Latitude i Q Hauler Q Indoor <br /> _......_..._[::]:T <br /> 0 Inactive Q Truck <br /> Longitude – O Planned O 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 O Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> i <br /> 'V A HAULING AND MANIFEST REQUIREMENTS- Q Notice Of Violation Extension <br /> - --- -- <br /> O O PRC§42951 Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / FT] <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 O 14 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 O In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form Included: O <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �. 62081 <br /> INSTRUCTIONS ON BACK Correct:9 incorrect: X � \/ jE Xi <br /> A �4[P l_ U I <br /> ! White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />