Laserfiche WebLink
ca� Waste Tire Ey & Inspection Repo"Inspection Report Number <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 Il - 1143323 <br /> California Integrated Waste Management Board <br /> Part A-SurmaBLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site suffix: ` l O ,fr O ' .0 Routine Q Re-inspection Q Referral Q Observation <br /> Localt ,1 If Referral,choose referral type(Fill one) <br /> Identifier: SCkI)10MU1f1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name LL Inspected By Inspector <br /> Physical Addre s 3 { V I <br /> Inspection Date � / � � / I b <br /> Time In Time Out <br /> Business Rep J Title A * AM / 0 AM <br /> \CJl\ .` moo' ,- i _{ U -0 PM fi PM <br /> ` S Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active • Passenger 40 Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle f <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / W <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M M <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Re wired for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 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 1 Q 1 Other: § <br /> Comments2f)1 N ALIT 4-600, (k ln� �o�IOw1nT A���ne <br /> 00 0\ukl' Dns b s u"cC Jus (h <br /> N e �. FWCAIA. W 0 0CUVel 1L 6'dlef <br /> Inspection Form Included: Q <br /> Comments Included: Q — - 06—�'—E-����" �'SSigna.ture <br /> inessRep's Signature PhoneNumber Inshone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X i 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink V0111K <br />