Laserfiche WebLink
Waste Tire Su. - ay & Inspection Report Inspection Report Number ■ <br /> ri3l. State of California <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 I1 - 1144010 <br /> California Integrated Waste Management Board - - - <br /> Part A-Survey <br /> BLUE OR BLACK INK PE <br /> Business Profile Inspection Details <br /> TPID- Inspection• - Inspection Type (Fill one) <br /> Site Suffix: b o 5 u` 4PRoutine Q Re-inspection Q Referral Q Observation <br /> Local ! If Referral,choose referral type(Fill one) <br /> Identifier: SGt(� 0Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address &n 5CA-0 <br /> Av-, - -- - --- - <br /> Cfl Inspection Date <br /> Time In Time Out <br /> Business Rep Title 4k AM S 10 AM <br /> �,1' OPM OPM <br /> JC� VoL(-\ au-, (�UUrn Cae n.rn r. -- -- - - ---- - <br /> - - - - - Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 19 Active Q Passenger • Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler • Indoor <br /> p Q Inactive Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> i <br /> jQ Service Station Q Hauler Q Agriculture Q Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q li Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> I <br /> Q <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments \� i I M ' <br /> 14 <br /> � 'rC s <br /> Inspection Form Included: y l �� <br /> Comments Included: 4B � <br /> � ` - �"��-" (IA)Ll "_�I7" <br /> Rep Sig ture Phone Number Inspe or's Signature Phone Number <br /> - <br /> - - __ <br /> '41 <br /> INSTRUCTIONS Correct: Incorrect: E A 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy: EA <br />