Laserfiche WebLink
Waste Tire Sui ;y & Inspection Report Inspection Report Number <br /> '1` State of California <br /> CIWMB 181(NewSurvey Form - Page 1 I 1 - 1140824 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Site SuffixTPID- , Z 2 S _ / Inspection Type (Fill one) <br /> : 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5y - 4�, , , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name OInspected BY Inspector <br /> /� f� P <br /> Physical ddre`ss x/'"rrs / /Gt�Y1C�/JU Ac�"� � - � O q <br /> i <br /> —_ Inspection Date / <br /> 1 ru C/� �is3oy <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> PM Z ® PM <br /> — — Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> / 0 Active 0 Passenger 0 Generator i 0 Outdoor <br /> PS <br /> Latitude O 0 Closed 0 Altered <br /> CI0 Hauler ® Indoor <br /> O 0 Inactive ®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 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A j HAULING AND MANIFEST REQUIREMENTS <br /> ._.._ _— _- _. ---I 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 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 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 - No Violations <br /> 0 0 Other: § <br /> Comments <br /> 414 <br /> Inspection Form Included: O <br /> 0 2- <br /> Comments Included: ® �r , <br /> � _ __-Bess Re Signature Phone Number ature Phone Number_ <br /> / 62081 <br /> INSTRUCTIONS O BACK Correct: Incorrect: X �/ - A; P L 112131 <br /> White Copy:CIWM6 Yellow Copy:Operator Pink CopWA A <br />