Laserfiche WebLink
■ 'isia Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMBof California Survey Form - Page 1 1 7 . 10 13 7 0 0 <br /> CIWMB 181(New 04/04) <br /> califomla Integrated Waete Management Boertl <br /> Part A-Survey _ - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - <br /> TPID- Inspection- ® Inspection Type (Fill one) <br /> Site Suffix: v 0 Routine 0 Re-inspection 0 Referral 0 Observation <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 <br /> Inspected By Inspector <br /> Physical Address + /� �J ✓ / - t/� Su/3 CLQ yr���;� <br /> Inspection Date <br /> ` 7I Time In Time Out <br /> Business Re/pJ Title //� � / 0^ y n O PM / / � � *AM <br /> SAY/'Z4� O PM <br /> - - -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 ° 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O ! 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler � 0 Indoor <br /> =I active 0 Truck <br /> Longitude - anned 10 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <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 0 Other <br /> Part B Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> Ni A{ HAULING AND MANIFEST RQUt12f: <br /> EMENTS 0 Notice Of Violation 0 Extension <br /> 0 1 0 PRC§42951-Waste Tire Hauler Registration and I ransport of f ares <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-RegistrationlDecal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <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 p <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance - No Violations <br /> 0 0 Other: § ::J <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 V^ <br /> Busin Signature Phone Number Inspector's Signature Phone Number _ <br /> ■ INSTRU )( <br /> CTIONS ON BACa FIE1-T� 62081 <br /> - © ■ <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> L16--77014,4.1077„ <br />