Laserfiche WebLink
Waste Tire Su*ey & Inspection Reporo Inspection Report Number <br /> ® <br /> W <br /> .Sa" State of Californiarnix Survey Form - Page 1 I 1 - 1088193 <br /> Int CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board <br /> Part A- Survey _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection ection T <br /> f C , p Type (Fill one) <br /> Site Suffix: 2 .-' <br /> 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local �� j If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p Y Inspector <br /> L JA 7— <br /> Physical Address � � r �IA. .IX, <br /> .Street <br /> E^ Inspection Date / Lf_IA <br /> =l u <br /> tr __ State ZIP Code Time In Time Out _ <br /> Business Rep Title <br /> AM C AM <br /> L 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> " <br /> r (Fill one only) (Fill all that aPPIY) (Fill all that apply) (Fill all that apply)Count(Whole/PTE) <br /> r @ Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude O 0 Closed 0 Altered <br /> Q Hauler 0 Indoor <br /> • O 0 Inactive 0 Truck <br /> Longitude - T71 <br /> .,_I � �.��..<,... �.�P I I 0 Planned 0 OTR 0 End-Use 0 Container. <br /> Business Type (Fill all that apply) - - <br /> Q New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer 0 Auto Body 0 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 /> VII A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 11:1 <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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § - <br /> Comments <br /> f , <br /> V , <br /> Inspection Form Included: 0 1 <br /> Comments Included: Business Reps Signature Phone Number Inspector's Signature e p <br /> _ � " " <br /> g p g hone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X F 'X 9 A 1AFP L I el I I I Z 13 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />