Laserfiche WebLink
■ , _.dy:- \1 Waste Tire Sur* & Inspection Report spection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 11 - 1140812 <br /> California Integrated Wastt Management <br /> Waste Management Board <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> ,asiness Profile Inspection Details <br /> PID- '' Inspection Type (Fill one) <br /> Site Suffix: (9 tC U ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: S��yl -7�uc; r -.� (9u> � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility NameL/ --- - -- <br /> Inspected By Inspector <br /> Physical Address 3 <br /> 3 Pts,S CA -- <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title n O AM O AM <br /> U ® PM ' ® PM <br /> - Operational Status Tire Type Business RoleStorag <br /> e Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 ® Closed 0 Altered <br /> GPS Latitude ----- 0 Hauler 0 Indoor- - <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (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 /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other �Jl6I S ' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- ............_ 0 Notice Of Violation 0 Extension <br /> ---- ----- _ - <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 m / m / m <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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> ction Form Included: 0 <br /> t <br /> ----------- _ <br /> � Comments Included: ® ���—� � - --- > > Ulo�paBusiness Rep's Signature Phone Number nspecSignature - Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X ,,�, ;X A_jA P L EI �L� 62081 <br /> While Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />