Laserfiche WebLink
Waste Tire S y & Inspection Re or Inspection Report Number <br /> State of California /� I'} <br /> i. CIWMB 181(New Q4/04) ►Vi Vi <br /> V m <br /> California Integrated Waste Management Board . rve J Form 1 i lege -- <br /> Part A Surve BLUE OR BLACK INK PEN <br /> w!�fu ' w5" k ,4I iM1�4zf,y'�,R�'w,;,atkt�pG wt",Wry✓',V' FN�,k., i xrh3at �: <br /> B1151�1�".rK$7"�r4�lfa <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: _ ("� (4.) l_ J _1 -� DE (D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local F. --- -+ If Referral,choose referral type(Fill one) <br /> Identifier: „j r<< :( 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name i <br /> _ � CInspected By � Inspector <br /> Physical -- - _ <br /> Ph slcal Address <br /> 1' I <br /> Street �' ._ / l <br /> 1 Inspection Date ( , , Lo <br /> city State Zip Code Time In Time Out <br /> Business Rep Title O AM OPM 0 AM <br /> L <br /> �. rr <br /> LA i- <br /> PM <br /> I L <br /> Operational Status Tire Type�,dM( Business Role Storage Type <br /> (Fill one only) (Fill all that”, (Fill(Fill all that apply) (Fill all that apply) <br /> i &Active 0 Passey ) 0 Generator 0 Or <br /> o O Closed Altere ,l r <br /> GPS Latitude t!� *" _�k Hauler 0 Indoor <br /> r <br /> p 0 Inactive 0 Truck <br /> Longitude <br /> 0 End Use Container�T_1 . T Planned <br /> Business Tvpe (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station (5 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — ---- <br /> 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 m / m / m <br /> 0 0 14 CCR§ 18459.1 (a) (b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 4ft _V -t(lick� I(>fG f1� v)!s/ <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA — <br />