Laserfiche WebLink
_ y-ri_�- ... v..-_:,ems -.__- ._: .. w .".-... _.-. .-- r•++ ..:w—.s..__ -_ .... .._..+.�.-.a- s-- ir. .. - r... ... -Vr� .v-v.. -�— <ti_—.._� <br /> � <br /> Wgste-Tire Su1Y p p& Inspection Re o t% <br /> 'Inspection Report Number <br /> LLCS. <br /> State California <br /> CIWM 181(New 04/04) SurveyForm e 1 <br /> California Integrat€„ Waste Management Board - Page <br /> Part A- Survey BLUE OR BLACK INK PEN. <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ' 2 C O ( O Routine W�Re-inspection Q Referral O Observation <br /> Local rte- — (J If Referral,choose referral type(Fill one) <br /> Identifier: c. it �• _-fi Q CHP Q CIWMB Q Complaint Q Educational Visit O Other <br /> Business or Facility Name � <br /> Inspected By Inspector <br /> (Physical Address. <br /> StreeF- <br /> Inspection Date <br /> I <br /> City� ZIP IP Code <br /> �5 I Time In Time Out <br /> " <br /> Business Rep Title 0 AM O AM <br /> MOPM m0P <br /> n� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> =Active @ Passenger &Generator 0 Outdoor <br /> m O Q Closed 0 Altered <br /> GPS Latitude I I I . Q Hauler � Indoor <br /> (� O O Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair (R)`Trucking Fleet Q Government Q Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A '.-'HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> Q O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline . <br /> Q .0 PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m / m <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> --------- <br /> O 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> — --- - <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O 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 a. In Compliance-•'N6`Vic lations <br /> O O Other: <br /> Comments ,,!.^ LG;;' -/ —>/r� �I�� �J'•; �� �`?,.—3-rte 1 t S f� .a� —/ 1 <br /> ���P _^,,. �.,T t"S fir y, '�^� "T✓r" �_ .y/?<iYi <br /> nspection Form Included. 0 <br /> Comments Included. . -- ' <br /> Business Rep's Signature Phone Number Ins ector's Signature Phone Number <br /> U/ ��� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ) '� �/ � ,�+ I�r"i �' L � 1 Z .� <br /> -n. <br /> ■ White Copy:CIWMB Yellow Copt's Operator Pink Copy:LEA ■ <br />