Laserfiche WebLink
® Waste. Tire Su&y & Inspection Report Inspection Report Number <br /> °--' State of California <br /> �� � CIWMB 181(New 04/04) Survey Form - Page 1 3_- _1 a-2 5 8 6 5 <br /> California Integrated Waste Management Board - <br /> Part A Survey BLUE OR BLACK INK PEN <br /> ii Ul. <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I (� t� (-� L �� Q Routine �'Re inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �': \ . , !. + 1 j Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address .(A c <br /> Street <br /> Inspection Date <br /> City State ZIP Code. Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> F-1-1 O PM LU.' O PM <br /> �rl �� L Business Role <br /> Operational Status a ,� , <br /> r <br /> (Fill one only) "r( ri11✓ }(lft f r p (Fill-all that apPlY) 5,� 11f eil fled air )" <br /> "ka Y.�l 'v"/// }a ) 9," 1d`t��.gni"h'`�Y �✓ ti .LA ✓/tlY q•^� ,g X <br /> r '" +f fsrs i i/""d fr ✓✓: "p✓' 4 11 (9 Active ri QQakP �n°. Generator �w t f XvSp"rl,fa: <br /> -I�_a .t 'I �Yapr" 5a ✓ w Efr p17aMr 'a tru ra t <br /> Latitude Q Closed <br /> GPS <br /> pqr✓! a t rrt� p <br /> +� <br /> Q Hauler <br /> Q Inactive !"Q <br /> Longitude — Q Planned F�y�r" t' Q End User �rr rr 1 <br /> f'k^titrws�.r <br /> ,� fa.^;^.la„Y`"�6 r^ ~ri r F"✓. Yr rr' ✓rr.en.. � ar;rA r s...,.T< �f}ra..;' �' �. a, I ,i"✓�a/ pr" r ✓".}, ¢.,a n�',^ /ara <br /> ,t . n ^" +' d; J S ,f'^ ,� rl „✓+ r >r Mr,":�.+r r P d u'1 as,wrl r a.r 3 rr' r.r a , r ” ",, 7 aik. p ^�'f9 d - <br /> .., ,�' /... r r / � pnr r,',,a:;� adir;�'!p.�..� '��,���a�c �2,�/l^,l.v..a.�.u,t.�.���Sp?,a,;:* .k" „�.1;�.€ l""6p/I ii',�"���r"�n ry✓.�s.�fv�.;.�a_vf,�i"al.>;•��.,�'"'r.,v!�r^"f"" u <br /> i <br /> Q New Tire Dealer Q^IAuto 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 Q Hauler Q Agriculture Q Shredder Other L.M r2 1^ r- r:111- <br /> Part <br /> 1!>Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use FacilityENFORCEMENT STATUS <br /> _ _ <br /> V <br /> 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 DatuM / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <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 <br /> y In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �I'NISpOCtIQI#i'Or11'! Inl�d$f Q� r / <br /> u mess ftep s i rs #ure" 15h----- tuber „f I' ",^, Phcahe,lVurn bey.`. a <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect X <br /> ■ - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />