Laserfiche WebLink
r� s N <br /> F'== Waste Tire Su&y & Inspection Repor, Inspection Report Number t■ <br /> 6O�0u State of California - 12 . <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r,1 Inspection Type (Fill one) <br /> Site Suffix: V �� j h✓ i <br /> Routne Q Re-inspection Referral Observation <br /> Q. Q <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: va `n_ <br /> _ tn, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B — <br /> f!,, P y Inspector <br /> I <br /> JVI a V tfk cr <br /> Physical Address 'J� I DOrC( 0 C I <br /> ' Street <br /> _ )n ?7� Inspection Date <br /> f City Title � AM State ZIP Code Time In Time Out <br /> AM <br /> Business Rep Q' <br /> PWif S Sc"-V -P m O PM m m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) l�f '1 7 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d J Active Passenger Q Generator .Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS m • Q Hauler Q. Indoor <br /> O Q Inactive Q Truck <br /> Longitude — FT---F1 - I I I I 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 I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _. . . ------- ---- <br /> V <br /> -V A 1 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 <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 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> -— - - - -- —..... ............. <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 /> -----. . ._........... ------. ._.......-... <br /> _ <br /> Q (5) 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Comments <br /> Roli, fit ft _ � �-�t� �� I�tai-��� `/L< S <br /> �- L Ga ✓ 1-Cts <br /> vV ;mss r. —1s _wno <br /> 5�f7 <br /> VL <br /> Inspection Form Included <br /> Comments Included. ( j /CSL l I ) _� << /I <br /> Bust s's ep s Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: '_ � d I 0XI.A1141 P IL I El 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> i <br />