Laserfiche WebLink
�!�!�e Tire Sur,,- Inspection Report <br /> In :.ction Report Number <br /> ■ &3G;uSu rnia <br /> Survey Form Page 1 ( 3 - 1 0 1 3 7 5 4 !, <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board . _ <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> SIt1 ,S bra �'� a6 ,>s � x ��� �'' a q 7 "� r^'1ir4 ? Ln Fa! W G ✓r <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: J 3 5 ! � Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Yl, ��Gt (✓t(� ! (;�( �. r _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name t. ' <br /> Inspected By Inspector <br /> M o <br /> Physical Address <br /> Street <br /> t <br /> Cit F0 Inspection Date <br /> ' 'l�� ,} f ,l 7 <br /> -ltY' 1 State Z1P Code Time In _ Time Out <br /> Business Rep Title f fqP <br /> M AM <br /> .t r- ( 0 PM <br /> QPM <br /> lift Operational Status %�� q�fri Business Role Storage Type <br /> (Fill one only) ( tll ) tMtirrr (Fill all that apply) (Fill all that apply)I <br /> ® Active Q{'I (a Generator Q Outdoor <br /> D <br /> Latitude Q Closed 01 <br /> GPS 11Q Hauler Q indoor <br /> -- C Q Inactive Q Truck <br /> Longitude — Q End-Use Q container <br /> Q Planned QO'1'R <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 ,): ( ! _ o <br /> ku <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q I Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 m / Ell IE <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 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q I Other: § <br /> CommentsL( / <br /> : ..� � fYvt <br /> i_, ; <br /> YJ <br /> JK �Jel Ic`'% /�v j� I <br /> -! 14t{/[ / l riff <br /> IV <br /> I <br /> n V < I <br /> t �. <br /> Inspection Form Included: Q <br /> Comments Included: Q _ <br /> Business Rep's Signature Phone Number I;M, E r� :5 of re Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A'M P,! i2 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />