Laserfiche WebLink
sp_ectiort Number <br /> Waste Tire Su ,..- _-& Inspection Report -on Report <br /> a <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 6 - 0 13 3 4 1 <br /> California Integrated Waste Management Board -------- -- --- --- --- ------ ---- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> �. <br /> m M <br /> TPID- - Inspection Type (Fill one) <br /> Site Suffix: ` �`J r7 0 Routine 0 Re-inspection 0 Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. J� L_.-N 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street ` <br /> Inspection Date <br /> I <br /> City State ZIP Code Time In _ Time Out <br /> F 0l <br /> Business Rep Title O AM O AM <br /> PM EJ_1 F._...._.__ O PM <br /> 1 /1i'_.. �-7.zJ­// -5 11 '�� ---E <br /> lillill:Is iii , ,Operational Status +�> r r, ..„ Business Role Storage Type <br /> 9 rFill one only) two )I rlr" f,,t„t r Fill all that apply) <br /> J( Y) (Fill all that apply)���d�r � i� ( <br /> r r a F <br /> b l Q0 Generator 4?tld4�or j <br /> ,. Active 4 1 Nn M� <br /> `Nr rirJwl y/*” "udiMY <br /> Closed ��a� ��r/n4 <br /> Latitude , art a <br /> GPS a tHa Hauler sOIrCor <br /> D 0 Inactive <br /> / � m <br /> Longitude - 0 Planned i � 1 t End Usei ttf�el <br /> V', rd M t..rr r rl, gr. Y1(f r r ti•f'«w`"x 'xr+fi E^N,„r x err ,moi,,„ <br /> .''' "., ',' + W.+ a ^"" aW„ - ,a b� :; d➢ !, ;., m �,� <br /> ( .r,r ��� er >w 4e ,+,�sfl/➢ e„ _ �' ��da�: r k; <br /> „. s.:;: t :... a �+(!d �::r1�n wrr..r, .5m. ..»�. r... .r .. ➢d t'..-,t ,a.....��� A... :,. >.. n a , .,r-�'... a <br /> ,„- <br /> __ <br /> New Tire Dealer 0 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 /> 1 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 <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m m- <br /> 0 0 ,__­(Required for NOV or EXT) <br /> 0 0 <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <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 Other: Generators ;In Compliance - No Violations <br /> _JI <br /> Comments <br /> — <br /> ( ..T <br /> INSTRUCTIONS ON BACK Correct. Incorrect: X �, i A M 0?� � rl 1112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © S <br />