Laserfiche WebLink
Waste Tire Sty & Inspection RepoInspection_ _ °rt "umber <br /> ■ Re <br /> • State of California- p <br /> CIWMB 181(New <br /> 04/04) Survey Form - Page 1 <br /> I1 - 108699 <br /> California Integrated Waste Management Board <br /> ---- — — R� <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> BustnessfrofqeA Inspection Details <br /> TPID- (� Inspection Type (Fill one) <br /> Site Suffix: _4I L/ ! �� / ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier: ( OCl i(,�`it �h� / 0 CHP 0 CIWMB 0 Complaint 0 Educatybnal Visit 0 Other <br /> Business or Facility Name r Inspected By Inspector <br /> Physical Ad r 0s � D=aj <br /> �Z <br /> S 1`V1 a.l <br /> Street (_ 71 <br /> (� ) J � Inspection Date <br /> Time In Time Out <br /> City State ZIP Cade _ <br /> AM <br /> Business Rep Title m <br /> O PM I__.�1 I O PM <br /> - �^ 1 9- yp <br /> Operational Status Tire Type Business Role Stora e T e <br /> ire Gount Whole/PTE),, <br /> t f. (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply), <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0,x� Closed 0 Altered <br /> LatitudEE .LH = <br /> 0 Hauler 0 Indoor <br /> GPS0 Inactive 0 Truck <br /> Longitude - � ,FTTT7-"o Q Planned OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) O O -. — - <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Dismantler 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 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. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m m <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 EXT) <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 0 In Compliance - No Violations <br /> 0 0 Other: § ----. _. <br /> Comments <br /> 0('tt�'t�I= rk' � t� S Cert Si�P . <br /> /7 <br /> Inspection Form Included: 0i <br /> Comments Included: - - _ <br /> 0'Business Rep's Signature Phone Number Inspector's Si nature Phone Number <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X j X i A 14` (- 1,1213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />