Laserfiche WebLink
Waste Tire Su & Inspection Repor spection Report Number <br /> `State of California .+� <br /> CIWMB 181(New 04/04) Survey Form - Page 1 $ i 7 <br /> California Integrated Waste Management Board --- - - <br /> Part A- SurveyBLUE OR BLACK INK PEN <br /> 11 <br /> speotlbn Deta".., z�xd„,:_; �.. r.!.�l <br /> TPID- Inspection Type (Fill one) ._. <br /> Site Suffix: I m 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> C':� <br /> Physical Address - �- b ! t.; <br /> Street Inspection Date <br /> I----- ---- --- <br /> City State ZIP Code Time Time Out <br /> e In_ <br /> Business Rep Title AM ELI <br /> O AM <br /> 0PM -1 0P <br /> Operational Status �t M '� (Fill allBusinss that apply) 311 <br /> 1 <br /> i ( y) <br /> � t( <br /> G)y 0 Active F 0 Generator <br /> 0 0 Closedti, <br /> GPS` Latitude � tiy i �t 0 Hauler <br /> turi <br /> ® inactive <br /> Longitude - Planned r' � r � 0 End Use <br /> u a <br /> `"`^ `°� ,��. ,;..r ,. a:. r:,` «t iu"C�P�i,..V "t;'a�,yv 1w7 4i w?rrr zA�`:,„sw�%"Rx-,"'m <br /> Buslnie T Y IIV a , 'd ;„; i. t.d �t� ,'F. t � G ' vM irr <br /> �-Lw 'st",..,..Y.r :a�at 7 t.."�,.....�, � t',� , <br /> 0 New Tire Dealer (A) 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 HAULING AND MANIFEST REQUIREMENTS <br /> O 0 0 Notice Of Violation 0 Extension <br /> 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 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 In Compliance No Violations <br /> 0 0 Other: § --- <br /> Comments <br /> ✓24 f"7 a ,{t ffr�;r0 ✓g ” °,+b ii i°�n3r 9 rW ,,��,;. a�, <br /> Inspection Form Included: ' <br /> Comments Included - - - -- .... <br /> 0,Business Rep's Signature Phone NumberjP-A ►', iur ,.-. Phone Number j <br /> _ _ <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X '�i V, Ii' i h <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ILA ■ <br />