Laserfiche WebLink
Waste Tire SuW & Inspection ReportQnspection Report Number <br /> State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 6 <br /> - <br /> 1 Q t 3 Al <br /> California Integrated Waste Management Board <br /> ' - _-- Ins - _ -_-- —� <br /> art A- Surve BLU <br /> Business Prof1" Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I I I 3 I y I I I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local I It Referral,choose reterral type(rin one) <br /> Identifier: , i TJ(i �!,C�l 161"+r�Yl�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ' 131(1 Idoll <br /> 1 �qWit • � a#"fit✓c,� = C I <br /> treet <br /> Inspection Date <br /> - <br /> "U <br /> kv St�fif, ZIP rude Time In Time Out <br /> Business Rep Title O AM 1 O AM <br /> + ! ! ( t Irl / &k 0 PM I I I 0 PM <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) 1 Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude <br /> Q Closed Q Altered <br /> GPS ', Q Hauler Q Indoor <br /> J Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 4 Alt <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> O Q Other: <br /> �§'' � .}}�l�-�'l� / <br /> Comments h'r)liLItin Pil �u stilt bent --L)y1 /I/(( UL (1K ✓ ✓(t L/!J <br /> ��vfFZ.rr`i^�'� Nl1�6, C�tr; �rC��t 'vt <br /> A �`1 ) C� U l � '� tGtu.f h c7 firP Cl�'P I'PyN�i/P% n'vr'Y i <br /> a <br /> -__--- - •ter-`_e - - <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> _ Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X E XI R MI P i �I EI 11- I Z 13I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />