Laserfiche WebLink
Waste Tire- Sui & Inspection Report Inspection Report Number <br /> State`of California '' <br /> rr <br /> CIWMB 181(New 04/04) Survey Form - Page 1 1 - 1 0 1 0 5 3 1 <br /> California Integrated Waste Management Board — --- --- -- -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L' ? LL C` I - t_� I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J;` ; I i' �^ Lr �Lt,i V,' t 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address J �(� r I - ) i <br /> Streetr i Y ! r Inspection Date CJ �< `� LO <br /> CifJ �� l <br /> State ZIP Co ed Time In _ Time Out _ <br /> Business Rep Title AM O AM <br /> I <br /> _ 0PM �^ 0PM j i <br /> r e i r r't(;� '�G t 1 "( c� , f i`t 00 t, u( w d .rt��«i' Business Role Storage Type <br /> Operational Status g yp <br /> (Fill one only) f I I�t�d� (Fill all that apply) (Fill all that apply) <br /> ® Active � +� 5 " 0 Generator 0 Outdoor <br /> m _ o Closed 1lyt � i,r r <br /> Latitude �+a <br /> (jP5 l �f�rit�, t,i,���� 0 Hauler 0 Indoor <br /> C 0 Inactive ,� <br /> � 0 End Use 0 ContainerLon Rude 0 Planned NfOTR <br /> r rid rl <br /> eey� v� <br /> v , d,: n2 s," <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@ Other ( j <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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. I Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 I 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 2 In Compliance - No Violations <br /> 0 0 Other: § - — - <br /> Comments y / <br /> i✓P < i/' ✓, .r <br /> rvj(7 yt r f � ►--vI C ���) 1� L". <br /> `0i ��,, Uf I t11 r;� /�yC- ltpt "{' %7)1C_4 1�Cf �cctr� 'j�If <br /> ( ) f I1 ` <br /> -L1 1 �J1i �f r:ct ( ff<< ( '''.t !, �t. f (��l 1111) 1(a f j`j},, `; " ��e`�!' , 7,f( (i rra)e i(i' 10✓KSI ' ]i/t ) <br /> �rr6( M ,tWedr,K <br /> INSTRUCTIONS <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X , ,A P �T 1 I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />