Laserfiche WebLink
Waste Tire Sup � dy & Inspection Report .inspection Report Number <br /> State of California I 1 - 1141012 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> )art A- Survey <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 0 I 1 o I ® Routine Q Re-inspection Q Referral Q Observation <br /> Local t If Referral,choose referral type(Fill one) <br /> Identifier: San 36(k,11A i n C(9 At)A Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> y 39 d�Mej'o c(-N - n E <br /> Physical Address S60�6 <br /> Inspection Date I <br /> (A <br /> Time In Time Out <br /> Business Rep Title I l 0 AM <br /> � � 10 AM 5 � PM <br /> l Q PM ooll <br /> C(�(c�r t)15u�,- - - <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) Q <br /> I* Active ® Passenger ® Generator Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned ® OTR Q End Use Q Container <br /> Business Type (Fill all that apply) <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 `��, 1 u 1 . 1 M kt)t4r+1i1 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility f ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 i 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 O 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 /> Comments0(1till <br /> ` t. �reLl.f��!( .(�� -_ C1(1o. <br /> _�O\6W n� vans 04CCA'� - - <br /> Inspection Form Included: Q <br /> Comments Included. <br /> &1/ne,s Rep's Signature Phone Number Inspect s Signatur _ Phone Number <br /> - -- - - / 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ', i N)j1e X1 A M r lT ;� 11 j 2131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop L <br />