Laserfiche WebLink
& g Waste Tire S0 & Inspection Repospection Report Number <br /> �RID�.'� State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 I 1 - .0 4 4 <br /> California Integrated Waste Management Board <br /> Part A- urvey BLUE OR BLACK INK PEN <br /> •- - I p ---- -- - - — <br /> Business.Profrie^'�� 'L), Ins ec#ion Details <br /> TPID- G Inspection Type (Fill one) <br />} Site Suffix. OLA 0 Routine 0 Re-inspection 0 Referral (9 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - GYl 0'(1 C C)un U 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> �-1 <br /> Physic Address rteasrs S_ <br /> 9 Ell?E, < <br /> i \ G_Q T► 11e <br /> Street Inspection Date <br /> City <br /> State ZiP Code� �� I i Time In '. T_ime Out Business Rep Title 11 O AM <br /> ��__L� AM <br /> ' �.-. OPM ! 0 EL_ O PM <br /> I <br /> Operational Status Tire Type , Business Role Storage Type j <br /> Fy;N i fr 7Ra1 a ras yajr4i r <br /> FIII one only) Fill all that apply) <br /> (Fill all that apply) (Fill all that apply) <br /> grru s Kdp7r barye r,a r t nn6 7 zn - _- - <br /> h.• ® Active 0 Passenger Q Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive 0 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 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 I <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 /> - : A l - -- - --- Notice Of Violation-- Extension <br /> V A I HAULING AND MANIFEST REQUIREMENTS O O �! <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 / m 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 /> f J No w r,�_ e -- ix'eS S�-oY-e_a oy-)- ►-�E o,Cr oy-Nr"t0 lJJ1tS()� c <br /> 1000 01 -to per orrn <br />} I:_erycc Yr)r\nI t hc�vf <br /> Inspection Form Included: 0 <br /> Comments Included: 0 -- <br /> Btlslress Rep's Signature "N <br /> Phone urnber In ec or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �, V �, A � T, _ 11213 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />