Laserfiche WebLink
w <br /> ■ 'ices: Waste Tire Sui0y & Inspection Report Inspection Report'Number ■ <br /> E6= State of California. <br /> CIWMB181(New 04/04) Survey Form - Page 1 '1 3 - 10 .1 . 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- + / ti ;Inspection Type (Fill one) � <br /> Site Suffix: J tJ' 0 j j 1 ,(E) Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: __:0 t f 'O CHP O CIWMB Q Complaint O Educational Visit O Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> Physical Address C� lo I ' ll )e r t -ru;.( <br /> I ) "I ? f...1 <br /> Street t <br /> Inspection Date <br /> City (;' State ZIP Code Time In Time Out <br /> Business-Rep Title O AM O AM <br /> c . „//. r �// mm0PM m � m 0PM <br /> {Av'l.it�.,1 ---- --- - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Gf (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f Active Passenger Generator 0 Outdoor <br /> ----F1 D Q Closed Altered /�•!/ <br /> GPS Latitude m . O Hauler 0 Indoor r <br /> O Q Inactive Truck <br /> Longitude — O Planned 0i OTR0 End--Use 0 Container <br /> _. <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS . <br /> V j A 'HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / M / M <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 <br /> 14 CCR§.18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years --......... ....._.......... .. <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _ _ _ <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 0 O Other: § <br /> Comments -, <br /> _ P0%d'c�t_C //�-JPC t�>, # r.� �F� .� ^flat 1 VI._ ; Was n 01,-,-( a <br /> �. <br /> t! TbS {./ /1ff lIKVIC(- dCi._-)0S0X, . CTL VI AJIF4 Na t° : 461 , fe�t0, G <br /> 1,-- ekP,1 Qvic� KzQkye syyill.�ti1_ rP w.s f- ;r) advapf.r fw -V0(Y'A1-:0-0 /1/:) <br /> V <br /> nspection Form Included O; <br /> Comments Included. -_.-.-._. - - � . <br /> Business Rep's Signature Phone Number Inspector s`Slgnature Phone Number <br /> . X r' 62081 <br /> INSTRUCTIONS ON BACK' Correct: Incorrect: ( } Ih�t @ .� 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> F7 <br />