Laserfiche WebLink
® i Waste Tire SuAlky & Inspection Report Inspection Report Number <br /> State of California ■ <br /> fora Survey Form - Page 1 I 1 - 1088133 <br /> CIWMB 181(New 04/04) Y ry <br /> California Integrated Waste Management Board y _ - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> 1:1111111aza:MEN <br /> I3usPnessl Profile, <br /> TPID- —� ++ ! Inspection Type (Fill one) <br /> Site Suffix: �j 1 ` ® Routine Q Re-inspection O Referral O Observation <br /> LocalT If Referral,choose referral type(Fill one) <br /> S�� �� <br /> Identifier: la) 0�n 9 , _�l Q CHP Q CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C onGCe _. l _ <br /> Physical Address I 19 I © f LX <br /> f L, , I —U C -S <br /> c_.-7ti 9 s. an s .�u._sSt <br /> Street <br /> Inspection Date I <br /> GIT-'7 <br /> ? ] / 'Zrj-_ / ��0 <br /> ✓�YY.1 <br /> 1 <br /> city State Zlp Code 9fLTime <br /> ...GiII�n lfTime Out <br /> Busp TrO ! 0 AM <br /> E3deCttCI1cat _._ _ PM 1If 11i�i9i <br /> L_.._....1�. OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> qj 2- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active 0 Passenger Q Generator 0 Outdoor <br /> (J <br /> Q Closed 0 Altered <br /> GPS Latitude . ` O Hauler O Indoor <br /> ® Inactive Q Truck <br /> Longitude — + O Q End-Use O Container <br /> P Q Planned 0 O rIR <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O 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 ® Other G I I Q y <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> 0 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O li 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem T / m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> -- —._ -- ---- ------ <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Ig) In Compliance - No Violations <br /> Q QOthe <br /> -- —- <br /> Comments (" <br /> K 00 Ir12 tri PSG t CJ17_ Qr�c>YrrtE 46— Acli C f)o 1�e C <br /> Gtc. tV� <br /> EOT martJz, i f� rT�) r <br /> 7111,191,�13111 P1 <br /> - - -- — <br /> Inspectl-4 <br /> � t <br /> Comments Included: (' <br /> Business Reps Signature Phone Number sector`s Signature 'y phrarte:r4tnrber <br /> INSTRUCTIONS ON BACK Correct: Incorrect A E X'[ , " P L — 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />