Laserfiche WebLink
::Jll <br /> Waste Tire S�ey & Inspection Repo Inspection Report Number <br /> 62State of California <br /> CIWMB181(New 04/04) Survey Form - Page 1 1 4 - i 0 25_0 9 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r- � � � Inspection Type (Fill one) <br /> Site Suffix: ( LoL/ Q Routine Q Re-inspection Q Referral Q Observation <br /> Locald If Referral,choose referral type(Fill one) <br /> Identifier: v1 ��rr (,tt,� o-l�lvt, O CHP O CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name Z' - Inspected By Inspector <br /> Physical Address �J r l - V , -7490r1 r (,ti <br /> �L _ . i -� � ��PY•tt ,��r• 1 I <br /> Street � <br /> ��� �� , Inspection Date <br /> I " l „ 6-1 -.,+ (�2� I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title Q AM 0 AM <br /> O PM O PM <br /> Operational Status ire Type Business Role forage Type <br /> Tire Count(Whole/PT <br /> O (Fill one only) Fill all that apply) (Fill all that apply) Fill all that apply) <br /> T #Active Q Passenger Q Generator Outdoor <br /> W I IO Q Closed Q Altered <br /> GPS Latitude IL—ll�l JI_ll Q Hauler Indoor <br /> 0 Q Inactive Truck <br /> Longitude - Q Planned OTR End-Use Container. , <br /> New Tire it <br /> Q Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber j <br /> O Service Station Q Hauler O Agriculture Q 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 /> - ( Notice Of Violation 0 Extension <br /> 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 Q PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / / m <br /> 0 Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q (3 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 O In Compliance - No Violations <br /> 0 0 Other: § J <br /> Comments r- ocAdy Pres !i / c .yam.,/ r t, l J J 1k f 2i' "f <br /> rt lipx. ' S tag, Ihun.�lt •/�a4!(Fc �� W�PvjPG� Td✓ nlUn�lt p� Via. z0C, a�c <br /> iti!ct.tt>l� ,� ��P�rou ryt��, ��o� nt ✓�� Ir �1� �ur irI, tV c U n . �4('C' <br /> 5 r� — �� � i'Y, / t') �i '"L�1 � `� v '/ � Vp Grp . � 4c iv, o , , <br /> � f" <br /> Inspection Form Included: 01 <br /> Comments Included: =' " <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Numbe <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X /P \/ "fit IE.X A P 62081 n 3 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA <br />