Laserfiche WebLink
Waste Tire Survay & Inspection Repop onspection Report Number ■ <br /> ■ :.:IHi State of California <br /> CIWMB 181(New 04104) Survey Form - Page 1 Il - 1140933 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUEOR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: , 5 $ t"' Routine Q Re-inspection Q Referral Q Observation <br /> Local ` ` If Referral,choose referral type(Fill one) <br /> Identifier: S CAn v V uC/'�,�y fl 014 � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 6 Inspected By Inspector <br /> Zae)`6-SC-(-\ <br /> Physical Address <br /> --- <br /> nr Inspection Date <br /> Time In Time Out <br /> Business Re \\C( �` Title 11a M rn f � 0 PM � V, � � PM <br /> NIL AM 0 AM <br /> uN1Q1.51r� \ Q 5 . ' 1 I f <br /> - -U�,/ Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) y/n (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> . Q Active Q Passenger 0 Generator Q Outdoor <br /> O .i Closed Q Altered N/A <br /> GPS Latitude I Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) T 0 1?1 <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 Q Hauler Q Agriculture Q Shredder Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> , ENFORCEMENTSTATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> I <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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 <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. § - - <br /> Comments L(iVa la, -4v i Je- <br /> 0-- 19u7�r Wt1,S fl oto-CA'• -- — <br /> ,Inspection Form Included: Q <br /> Comments Included: - — ------ ---- -- -- - �Slgnature(�&� <br /> .)Re 'sSi tVature tuber Ins PTSone Number <br /> B mes pg Phone u p — _ ----- <br /> . - �� 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: .M P 1 3 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />