Laserfiche WebLink
[®9_ <br /> Waste Tire Su°: .y & Inspection Report Inspection Report Number <br /> Stateof California <br /> CIWMB 181(New 04104) Survey Form - Page 1 11 1088092 <br /> California Integrated Waste Management Board <br /> Part A- Survey - - - BLUE OR BLACK INK PEN_ <br /> Business Profile Inspection Details <br /> TPID- {j Inspection Type (Fill one) <br /> Site Suffix: l 0 Ll p� p p� ( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ` /, If Referral,choose referral type(Fill one) <br /> Identifier: :SGy� 5Q(�Cb�I C©Ul� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical X141 rGC G` tom"`U /�l l S� h1�YJ <br /> Address <br /> Inspection Date O 9 Q <br /> ' ` cam `�� Time In l Time Out <br /> Business Rep Title O AM O AM <br /> ' U PM O ® PM <br /> any � t pry — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � f 7 tl <br /> l & Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 1HAULING AND MANIFEST.REQUIREMENTS <br /> -. - -------------- — --- 0 Notice Of Violation 0 Exten <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 <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers I 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® – 'I <br /> 0 0 In Compliance No Violations JJ <br /> 0 0 Other: § - <br /> Commentst�Y_1 ` <br /> 0,0� c�' e_Cwa,n i►Z U_ , <br /> �Gd-- <br /> J <br /> - <br /> re�nG -L3-cam( C .nv C� ��1�- <br /> aLip ? 4,-y-°s . N o _ v_i-qIct,-b_?, ice - <br /> Inspection Form Included: 0 _ Z <br /> Comments Included: 0 3 1 S / ;� o�` `! E469 <br /> usiness Rep's Signature Phone Number Inspecto 's Sig at a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK � n "' y XIAIMIPILIE1 1112 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />