Laserfiche WebLink
® Waste Tire Su*y & Inspection Report•Inspection Report Number <br /> EaW2�; State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 I �- 114117 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID I Inspection Type (Fill one) <br /> Site Suffix1 � � NI - 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> �_. .._ <br /> Local <br /> S / j If Referral,choose referral type(Fill one) <br /> Identifier. C/1 (�(,�� __� ( �µ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressW <br /> l..... .............__ _-............_ ......L...r .. _(J. ..._..__..._......A__V..........__........._.._........_.....I l <br /> JI ee` i <br /> 3...�.......�.r <br /> AInspection Date '; 0 <br /> CI i3 � <br /> ----- ��� ---- r� ��„ Time In Time Out <br /> State 1F ode ._.(.... __ <br /> Business Rep Title ( f AM AM <br /> 0 PM 0 PM <br /> Operational Status pTlre Type Business Role Storage Type <br /> ( (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count, (Whole/PTE) <br /> i' <br /> 0 Active 0asser:ger 0 Generator 0Outdoor <br /> D 0 Closed 0 Altered <br /> Latitude <br /> GPS 0 Hauler 0 Indoor <br /> t t---�---�--- Olnactive CJTruck <br /> C� <br /> Longitude — 0 Planned 00T 0 End-Use <br /> -L-��ntainer <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> r0 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 HAULING AND MANIFEST REQUIREMENTS <br /> _ __— _ —__._ _.— �— -- ' — — — ---- 0 Notice Of Violation 0 Extension <br /> O 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 m <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / M / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB J <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 I <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 Other: § _...._... <br /> Comments <br /> QIA -)_t <br /> Inspection Form Included: 0 <br /> Comments lncluded: 0 <br /> Business Rep's Signature Phone°aurnhcr ?lspectob`s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X r ,i A fP P LL,U 62081 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />