Laserfiche WebLink
Waste Tire Surma & Inspection Repo"Inspection Report Number ■ <br /> y p - Page1 18 - 1079437 <br /> State of California <br /> CIWMB 181(New 04104) Survey Form <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Profile Inspection Details <br /> Business <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: lJ V Q 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: C { u Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 3- 1 _\ A(I DI' wo <br /> Physical Address <br /> �5ai Inspection Date 3 <br /> L� C A t O Time In Time Out <br /> Business Rep Title O AM r O AM <br /> ` - 0 PM I ® PM <br /> y <br /> v;cp� S U�cl el` <br /> Operational Status Tire Type Business Role Storage Type <br /> C (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) J <br /> Active 0 Passenger Q Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude ' Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use ® Container <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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station 0 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 Q Notice Of Violation Q 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> Q Q <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 i <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 Q Other: § 1, -- ---(—� —(� <br /> Comments (� _ ,k: - 71XL a.\ (��j�Q�1�,� (lo(�-� 1 S <br /> to-a <br /> Inspection Form Included: V '6')Tv—� <br /> Q <br /> Comments Included. <br /> B ' ess Rep's Signatu/'re hone Number Inspect s Signature Phone Number <br /> - — ---- <br /> - -- 62081 <br /> INSTRUCTIONS ON BACK [�C�®rrec Incorrect � A hi+t Pj L E; 1 2 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />