Laserfiche WebLink
Waste Tire Su moy & Inspection Reporlo Inspection Report Number <br /> -`iii. <br /> ����- State of California <br /> CIWMB181(New04/04) Survey Form - Page 1 ( 9 10 7 2 8 71 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / / n _ © / Inspection Type (Fill one) <br /> Site Suffix: (P `� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 54n1 S N LOUN 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> VNrr'r__j PAze-g-1 SZ/t�r�Ge l D <br /> Physical Address NAU6A2 <br /> l 532- lJ 840 Ad(,.,,)A,/ <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep J De �S Title 0 AM 0 AM <br /> QdTa.�coT%JG 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> ,Z (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �O <br /> Active 0 Passenger * Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair •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 Otherr <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> HAULING AND MANIFEST REQUIREMENTS p .� _ <br /> 0 0 ` 0 Notice Of Violation 0 Extension <br /> PRC 42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. 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 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days {Required for NOV or EXT) <br /> 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years - <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement + <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance <br /> 0 0 Other: § <br /> Comments iNs,�u 77.tn <br /> 7 �D'f7 DYl /Am Kc-cJ� <br /> _/USc d_ �ra aNs TlcS OF roc rrt P.wf-o rl�S-�cr i S � {iYc `ta.µ/t r ✓�pica /.�,� ,� <br /> t'e3�-4"_ell-S ft/_ �JQG G�kcS__ <br /> U�1,4VAA: c�.ti re-. A!C _ _ S /fie v D� _c..�cS..'✓__e Fad _3 —7 <br /> Inspection Form Included: 0 �9 <br /> Comments Included: 0 - Aneso6j�s <br /> Bu Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI I 1 12 N 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />