Laserfiche WebLink
■ Waste Tire SuSlay & Inspection Repor# InspectionReportNumber ■ <br /> State of California - Al ! I J `-� <br /> 6&x3,S� <br /> CIWMB 181(New 04/04) Survey Form - Page 1 _ 9 4= <br /> a = <br /> California Integrated Waste Management Board <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Br — Inspection Details . '. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �i (3 6 if Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: [Sov TO L'O n ur <br /> T Co +k � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical ddress L�r�S �a�n_ LuC. t��f <br /> Street <br /> G '\ Inspection Date <br /> i S�- �--� ^j Time In Time Out <br /> city - Mate ZIP Code ......J-- <br /> Business Rep Title O AM � O AM <br /> � • PM • �.. 0 PM <br /> Operational Status The Type Business Role Stor <br /> (Fill one only) (Fill all that apply) (Fill all that apply) 1 (Fill althaISpI <br /> Active Q Passenger Q Generator Q Outdoor <br /> D Q Closed Q Altered x <br /> GPS Latitude , Q Hauler Q Indoor <br /> Q Inactive O Truck Q End-Use Q Container <br /> I <br /> Longitude O Q Planned Q OTR <br /> o <br /> Business Type .(Fill all that <br /> Q New Tire Dealer Q Auto Repair 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 (a Other - <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 /> MQ I Q 14 CCR§ 18459.1 -Tire Programram ID Number from CIWMB <br /> / m / m <br /> Q Q14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q I 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 /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q ' Q Other: - <br /> Comments' <br /> 9l�� <br /> JF-ac \li - . s ��_r1 �"C�r ,--fie r Y-u L <br /> ale-r � SQr } "4 - 1s1Y�-a1 �be -1-r�c-a <br /> Inspection Form Included: Q, <br /> Comments Included: - - - <br /> ,Business Rep's Signature Phone Number Inspe- Signature,,__ Phone Number. <br /> - P 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �/ I,- rlr� --' I_ i f 3 <br /> ■ �_- _ O ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />