Laserfiche WebLink
Inspection Report Number <br /> WasteaTire Survey & Inspection Report � <br /> State of Californi <br /> CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1127656 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> [[Business Profile Inspection Details <br /> TPID- i r� i - Inspection Type (Fill one) <br /> Site Suffix: J ` 5 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �{ (� ���Lq Ll l n ��{� � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 1 Inspected By Inspector <br /> �,(:)A , -cc ucki ns - E <br /> Physical Address 3 9 I <br /> 'Aoab C . M LLA t k Avc_ � ©q5a� Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 1 • O e PM ' 0 PM <br /> -- -- --- - - --- - -- ----- - Operational Status! Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> 9 C, S (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ' 0 Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 41Truck <br /> Longitude - 0 Planned 0 OTR <br /> 0 End-Use 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 j HAULING AND MANIFEST REQUIREMENTS 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. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 010 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 0 11 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 EX7) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <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 <br /> in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments &4111� F'`"-'-- - <br /> � 1 11 J <br /> oke _ a, '1► u MC co <br /> Inspection Form Included: 0 <br /> Comments Included: 01 <br /> u- c -- as-qq -�370 CaJ y�g-3�Vg <br /> Business Rep's Signature- - Phone Number Inspe or's ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK ' Correct:* Incorrect: X VI ] it X A P I L 10 [IT2 � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />