Laserfiche WebLink
■ Waste Tire Survey & Inspection Repo, . Inspection Report Number ■ <br /> California <br /> CIWMB 181(New 04/04) Surve Form Page 1 I 1 - 1140794 <br /> California Integrated Waste Management Board Y - J <br /> pert A-Survey _ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> ..-ID- H — Inspection Type (Fill one) <br /> v <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(,�{� ��yl�, �(}�(1{� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> E�re.oSb n oG IS��cs q 3 <br /> - 1 cel <br /> Physical Address J Gel Es coo <br /> oo <br /> CW_ <br /> ��� Inspection Date I 1 <br /> Yj� Time In Time Out <br /> Business Rep Title U 0 AM 0 AM <br /> I ` 0 PM <br /> ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> n,•r <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �y'J <br /> ' Q Active Q Passenger Q Generator Q Outdoor <br /> O + Closed Q Altered ►/�V1 <br /> GPS Latitude Q Hauler Q Indoor/A <br /> D Q Inactive Q TruckN � � <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> - - - — - <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q QQ Notice Of Violation Q Extension <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 FF / m / M <br /> 010 '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 I 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 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 /> Comments101 <br /> q , <br /> -- A,16 <br /> 0 -1�lU,11 Ons 5S U;(eus c� (�C2C wir)`, tOcC; �- hau - 5w1O_QAtA ko tv o0 5. rl an IA,_J AS o_(VM 4t UM-01 <br /> section Form Included: Qi 1 u q Q <br /> Comments Included: Q! u I `Cf14 `�u✓���u <br /> Business Rep's Signature Phone Number Inspektr's=gnature6A��JPhone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �,+ I IiTT 62081 <br /> - -- — <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />