Laserfiche WebLink
nspection Report Number <br /> Waste Tire Surly & Inspection Report0l[ ­ '_ <br /> St e <br /> at of California 1 .4 0 13 4 7 1 <br /> C WMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 3 <br /> TPID- : / <br /> Inspection Type (Fill one) <br /> F77 <br /> Site Suffix (# Routine 0 Re inspection 0 Referral 0 Observation <br /> I_ I Z/ <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> i J- <br /> Physical Address o t14 <br /> Street Inspection Date <br /> L C7�_ 151W01 <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title r [0 <br /> AM <br /> (*AM <br /> 0 PM 0 PM <br /> 2 <br /> Operational StatusBusiness Role ye <br /> (Fill one only) Fill all that apply) <br /> / 0 <br /> #Active Generator <br /> 0 Closed <br /> pS Latitude <br /> G 0 Hauler <br /> =1 - L_LLL__ Ll 0 inactive g)' in <br /> lk <br /> 0 <br /> Longitude 0 Planned 0 End-Use <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 service Station 0 Hauler 0 Agriculture 0 Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EINFORCEMEllit, <br /> V I'A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i <br /> i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB / m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 (j) 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> @ in Compliance No Violations <br /> 0 0 1 Other: <br /> Comments <br /> 0/_' !�:4 <br /> 0 � <br /> IX�2 <br /> '3 <br /> 4"MAM <br /> A <br /> "J" m-- <br /> INSTRUCTIONS ON BACK [Correct:* incorrect: 7 T-- 62081 <br /> I A M I P 1_ E <br /> A 7, <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />