Laserfiche WebLink
i <br /> Waste Tire Su#y & Inspection Repor )spection Report Number <br /> - _._ <br /> ®a®� State of California i I <br /> wr CIWMB181 <br /> Waste <br /> eManage) Survey Form - Page 1 1 7 - <br /> California Integrated Waste Management Board <br /> Part A SurveBLUE OR <br /> at Inspection Details <br /> LACK INK PEN <br /> 1111,11 <br /> TPID- _ - Inspection neReType (Fillone) <br /> _ <br /> Site Suffix: r 1 2.lel r) -� <br /> - r Q Q Re-inspection on Q Referral Q Observation <br /> Local I— u If Referral,choose referral type(Fill one) <br /> . Identifier: -�"Y� ,, -- <br /> . - ' <br /> ��i � ,�_._. =/-4p, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> Street - -T- <br /> -� Inspection Date ? <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> �_J� <br /> O PM F <br /> � O 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 /> Q ® Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude O Q Closed Q Altered <br /> Q Hauler Q Indoor. <br /> - f ���0 Q Inactive Q Truck <br /> Longitude Q Planned Q OTR Q End-Use Q Container <br /> i <br /> Business Type (Fill ail 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 <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Notice Of Violation Q Extension <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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 <br /> Q In Compliance - No Violations <br /> Q Q Other: §e <br /> Comments <br /> I l <br /> - J <br /> Inspection Form Included: 0: <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �, ,04 -� P_ <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA ■� <br /> .r <br />