Laserfiche WebLink
Waste Tire SUOY & Inspection Repor nspection Report Number ■ <br /> :,'2.21 State of California /_* e'� fl <br /> aaaasa CIWMB 181(New 04/04) Survey Form - Page 1 , a � ' <br /> California Integrated Waste Management Board a- - -- <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business-Pnf�1�, �Fnspecton Detai ': . ) '. ,, <br /> TPID- ! �, ry �, f r - ' Inspection Type (Fill one) <br /> Site Suffix. ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��v �� )`' �Dl-w y f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address l--� ✓ J / I � " �r� <br /> Inspection Date <br /> Street i1 <br /> Ins p <br /> Y G L/ _rate ZITime In / Time Out <br /> f ✓ ( ' <br /> Cil'. �.�.� l- ;ode <br /> 0 AM 0 AM <br /> Business Rep Tlitle O PMC O PM <br /> OpI Status Tire <br /> thBuloStogeapply):e <br /> ( I one only) (Fill all at apply)! ( ll althat apply) ( alt <br /> ', <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> - 0 Planned 0 OTR <br /> 0 Container <br /> Longitude 0 End-Use <br /> Business Type (Fill alhfh" <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 /> V I A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 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. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 14 CCR 18459.1 -Tire Program ID Number from CIWMB M / m / m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> OO <br /> 0 0 <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 1 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers n °?-r'erred/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 0 In compliance - No Violations <br /> 0 0 I Other: -- <br /> Comments <br /> Vj `� �Z•l t.t ! ,� r 7 i( +� �_ � �.(F' l '� _.f�' C t J <br /> t — <br /> Inspection Form Included 0 f <br /> (�� � � <br /> ��y; 111 - <br /> Comments Included, 0, <br /> Business Rep's Signature Phone Number Inspectors Signature Phone Number <br /> _ • X "/� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: � � 1 A i P .L E 1 2 3 �! <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />