Laserfiche WebLink
F_ <br /> 98129041122 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State it <br /> CIWMB181(NCalifofnle Survey Form.- Page 1 1 9 - 1 0 7 2 8 3 0 <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile � Inspection Details' <br /> TPID- (,� y ( - / Inspection Type (Fill one) <br /> Suffix:Site O I / 1 ]_�] <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ,/( _�' If Referral,choose referral type(Fill one) <br /> Identifier: L15_Z 'UQa Q CHP Q CIWMB Q Complaint' Q Educational.Visit Q Other <br /> Business or Facility Name n Inspected By Inspector <br /> ( <br /> Pint yicz, 1 / <br /> Physical Address <br /> ff_/___j <br /> Street + LEG]_j � 6� Inspection Date � <br /> City State 'LIP Code [T] <br /> Time In Time Out m <br /> Busin�es�s(Rep Title mOPM MAM QPMS i J <br /> ----- — - _ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) .(Fill all that apply) (Fill all that apply) <br /> I <br /> ®Active Q Passenger ®Generator Q Outdoor <br /> I 'O Q Closed Q Altered <br /> GPS Latitude L-- I „ !_�-__I_-—� Q Hauler Q Indoor <br /> Q Inactive ®Truck <br /> Longitude - I I I' I I Q Planned Q OTR 0 End-Use ®Container <br /> Business Type (Fill all that apply) <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 Q Other I I <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 m / m / m <br /> 0. Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O - - - <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 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 ®In Compliance No Violations <br /> Q 1 Q 1 Other: § <br /> Comments 7 — j ) ` d- '� Y� <br /> _l,cs�s M�Coo T�- r��rer�d A ce. � d,� aQ <br /> E2T— U 1/i —4 �ayi a1 8rt <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> Busin s Rep's Signature Phone Number Inspector's Sig ure Phone Number <br /> m, �( 62081 <br /> INSTRUCTIONS ON BACK I Correct:• Incorrect: �J �/J X .a M L E! ! 2 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />