Laserfiche WebLink
® Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 I1 - 1088443 <br /> Califomia Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- # � r-+� � � � t (J O � Inspection Type (Fill one) <br /> Site Suffix: l �Q/ �-{( 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �—( 1 If Referral,choose referral type(Fill one) <br /> Identifier: J S(�t� Q ckQ, 1 !t C©kA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Fa ility Name tt <br /> Inspected By Inspector <br /> 0 0.t _�c ,nQ <br /> Physical Address J 3 0 <br /> LO SQL <br /> Inspection Date <br /> (-A Time In JJJ Time Out <br /> Business Rep Title ®AM 9 AM <br /> o0 P 1 [QPM <br /> VQR4�r� u 0-� Naf\6U(r <br /> -Operational Status Tire Type Business Role ; Storage Type <br /> Tire Count (Whole/PTE) O (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> 1 ® Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive I*Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair ®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 /> '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. ° Compllance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> '0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 1!0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB 11 11 (( <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 /> i0 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 u e ' <br /> `otnblfarice bat "riS <br /> 0 0 Other: § <br /> Comments <br /> fou ��L N �s '�s 4 bVin� uxtS <br /> '�D U XiD cAbOS N aa(c_c is b+ C,6 Mo_f A <br /> ' = I• uc�t`t� � ,5 1��Oj�(�Il T ie 50104 O OLS -I��� �wtt -- <br /> Inspection Form Included: 0 /� jj��Qd !!''r)�/_ !t7 <br /> Comments Included: 0 $d�.-{3 X13 . �0 l_ 7b< 3f f <br /> Business Rep's �Sigre Phone Number Inspec is ign ture \\\\ P one Number <br /> INSTRUCTIONS ON BACK Correct 1 correct: I E'XJ A, MJ P J L J EJ I Z i 2� s2081 <br /> ■ White Cop CIWM I Yellow Copy:Operator Pink Copy:LEA �� ■ <br />