Laserfiche WebLink
=£g. Waste Tire Sul y & Inspection Report ,pection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1127875 <br /> California Integrated Waste Management Board <br /> Part A- Surve -- j Inspection Details <br /> � __ _ BLUE OR BLACK INK PEN <br /> Business Profile <br /> TPID- Ins ection T <br /> �? - 0 p Type (Fill one) <br /> Site Suffix: s 3 3 <br /> _ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � 1 If Referral,choose referral type(Fill one) <br /> Identifier: JC7Jv� r'1 0 CHP CIWMB Complaint <br /> ___ � 0 p 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address G - J <br /> -�-7 _ Inspection Date <br /> � l�tFJY/L�Un� U7 �S ��'6 l� <br /> Time In Time Out <br /> Business Rep Title <br /> S 0 AM � � r Q AM <br /> ® PM V ® PM <br /> - 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_ ® � g ® Generator 0 Outdoor <br /> Closed 0 Altered <br /> GPS Latitude O 0 Cl0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned .*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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other /y2iG�LG 42 <br /> L_. <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V "° ,°~ HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <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 j <br /> m / <br /> 00 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date [T] <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB �(�f <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Requirod 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 <br /> In Compliance - No Violations <br /> 0 0 Other: § <br /> - <br /> Comments <br /> oe <br /> Inspection Form Included: 0 y U <br /> Comments Included: ® /\ (�"®Fi2 3 <br /> _ Busine s' ep' Si natu Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON CK , 10 11,1213 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy: ® ■ <br />