Laserfiche WebLink
■ Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> =o;= State of California I 1 — 1140951 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> rt A--Survey BLUE OR BLACK INK PEN <br /> ,siness Profile Inspection Details <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: `7 `� -J f i Routine Q Re-inspection Q Referral Q Observation <br /> Local , 1_ If Referral,choose referral type(Fill one) <br /> Identifier Sato J d�j��N\ CU�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By r Inspector <br /> 6S5td& <br /> eory �cht�5�ol�.��ibnI � <br /> Physical Addre � <br /> -- <br /> �r�.c vJ <br /> 5� l Inspection Date 1 1 J- 3 <br /> CA w 6 <br /> Time In Time Out <br /> Business Rep Title I :AM 1 0 AM <br /> ' PM l O PM <br /> \ <br /> (.kf-c�cv-Q. -- -- - -- - - - --- -- <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) ee <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> --- ------ -- -- ----- — -- O (S Closed Q AlteredIrV/� N A <br /> GPS Latitude // Q Hauler Q Indoor <br /> O Q Inactive Q TruV/1( <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> J 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 Le") <br /> Part B -Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 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 /> 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 FJC� <br /> 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 <br /> ' ns f S <br /> Iiuspection Form Included: Q ' <br /> �Cfa <br /> Comments Included: ® CA, - <br /> Business Rep's Signature Phone Number Inspec 's Signature hone Number <br /> � <br /> � -�1. 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: V' X AMP 1, e 1 .3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />