Laserfiche WebLink
.............. <br /> 2v, <br /> V�X�_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California - 1140928 <br /> CIWMB 181(New 04104) Survey Form - Page 1 11 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> BusinessProfile Inspection Details <br /> - - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 IS 3 d I * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5�� <br /> 41 <br /> WU 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business-or F-ac—I I ityT—Na m_e <br /> Inspected By Inspector <br /> t_4,4c. 1 3 <br /> EsaPhysical 6o <br /> 2632, Uu&, Cre-AL, i)�- a <br /> (A Inspection Date 91 a 1 1 0 <br /> Time In Time Out <br /> Business Rep Title 0 AM o AM <br /> 0 0 PM 0 PM <br /> 166vit-vIfN (L4 - <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 /> Tire Count(Whole/PTE) <br /> Active if Passenger 41 Generator 0 Outdoor <br /> - <br /> GPS Latitude 0 Closed Altered <br /> G 0 Hauler 0 Indoor <br /> 0 0 inactive Truck 0 End-Use 0 Container <br /> Longitude 0 Planned OTR <br /> Business Type (Fill all that apply) <br /> Auto Repair 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> New Tire Dealer 0 Trucking Fleet Government <br /> 0 used Tire Dealer 0 Auto Body 0 car Dealer Collection 0 Crumb Rubber <br /> 0 Service Station IS Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> OF020 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 <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> m <br /> 0 * 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 I 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 7:1 0-All 4A <br /> 7%, Az& CASA ±13c, <br /> 0-cy-NIWA-1) DIM <br /> ,Inspection Form Included: Oil <br /> Comments Included: 0� Phone Number <br /> l Business Rep's Signature Phone Number -InJRr'A�Signat4urez <br /> M FA <br /> I I It 213 62081 <br /> A Pl � <br /> INSTRUCTIONS ON BACK Correct:* Incorrect. X\�� ,,\/ Fe X)( m—FP—'.,. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />