Laserfiche WebLink
® Waste Tire Su 3y & Inspection Repor= Inspection Report Number <br /> State of California <br /> CIWMB 181(New04/04) Survey Form - Page 1 I 1 - 1140672 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 / / s v _ / Inspection Type (Fill one) <br /> Site Suffix: l� to * Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � � 71 CAL -,V) CCCJ <br /> LL44 � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Ll <br /> X023 � , Ma�✓�- �+: <br /> Inspection Date / l 0 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ncA-ia(abwn� <br /> ✓l�e ( - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 2 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active • Passenger 0 Generator 0 Outdoor <br /> � 0 Closed 0 Altered � j <br /> GPS Latitude 0 Hauler 0 Indoor <br /> Q 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> I I <br /> Business Type (Fill all that apply) <br /> _ New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 /> - <br /> V A HAULING AND MANIFESTREQUIREMENTS 0 Notice Of Violation 0 Extension <br /> .......... <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 m / m / m <br /> 0 , 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <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 /> l <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 Generators ® In Compliance No Violations <br /> 0 0 Other: I - <br /> Comments <br /> -- u-v -i Ag— —Ir1(-r u,-i uw tr.^— <br /> ✓kJ}Cc�� �J <br /> Inspection <br /> Comments Included: ®' <br /> Bus 1nes Rep's Signature ne Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X �/ E° A L1 111213 620811 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co ty <br />