Laserfiche WebLink
Inspection Report Number <br /> ■ W^ : w Waste Tire S ey & Inspection Repor� p p <br /> State of California s — -., - ■ <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i ! " <br /> California Integrated Waste Management Board s = J —, Q <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> tn; nspecto4 4POO <br /> It -- <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L , %T - { <br /> ` . Routine O Re-inspection Referral Q Observation <br /> Local _ — - —— ----- If Referral,choose referral type(Fill one) <br /> Identifier: { ( ; / <br /> ,' r 0 CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> Physical L_ <br /> Address <br /> Street <br /> r, <br /> Inspection Date <br /> =/ C11 / .'� �, • / U � <br /> City State ZIP Code Time a In_ _T Time a Out 0 AM <br /> Business Rep Title _ O AM ^ <br /> �0PM <br /> L� L-L.'! 0 P <br /> Operational Status Trre;Type Business Role Bich Type <br /> t ; (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> ;Tire Fount�1llihale/ 'fl ) <br /> W•",t', { ""�.,'�"', M�, `a L, ° ` m,0"'•I JLJ ® Active ^�,PaSisehger (D Generator 64466r,,Latitude <br /> D Q Closed C7 Altered <br /> GPS Inactive truck O Hauler Q ►ndo r <br /> O <br /> Llanned Q End Use Container <br /> Al <br /> ongitude <br /> op <br /> ausrnessTe.(F <br /> Q New Tire Dealer Q Auto Repair Z Trucking Fleet Q Government O R_e_tr_ead�er� O Dismantler Q Tir_ew,. <br /> Derived Fuel <br /> O Used Tire Dealer O Auto Body Q Car Dealer O Collection O Crumb Rubber <br /> Q Service Station O Hauler Q Agriculture Q Shredder O 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 /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators w In Compliance No Violations ,I <br /> O 0 Other: § - -- - -J <br /> Comments r <br /> -- - Ir <br /> !Inspection Form Included,. Q' " <br /> Comments Included d�. . - - -- t - -', <br /> - Business Rep's,Signature,4 `Phone Number Inspecttor s Signature y � Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect ' '�4 1, 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />