Laserfiche WebLink
Inspection Report Number <br /> ■ Waste Tire SG�ey & Inspection Reporo -p p ■ <br /> State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board - - -- <br /> Part <br /> _ A- Survey BLUE OR BLACK INK PEN <br /> Business Profile' lnspecfifon Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix <br /> 1 JW Routine Q Re-inspection Q Referral Q Observation <br /> Local �r- If Referral,choose referral type(Fill one) <br /> Identifier: R �) v 1 t. t t �- OUB: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address �C, L 1-0L, L <br /> Street <br /> �} f Inspection Date <br /> 10 ro <br /> Time In Time Out <br /> city State ZIP Corte <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> - -Operational Status Tire'7ype Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)!, <br /> (3 Active Q!Passenger 6 Generator 0 Outdoor <br /> C Q Closed Q Altered <br /> GPS Latitude ��_1 • ��� 6 Q Hauler Q Indoor <br /> 13)D Q Inactive -Truck . <br /> Longitude - Q Planned Q 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 J& Otherr J <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 <br /> FTIFTIM <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 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 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 Other: § <br /> Comments 'n <br /> T , <br /> = c s:1 �` e 4��.0 _7rY_u..:.k 7jrr -f,EYyts r�; <br /> Inspection Form Included: Q <br /> Comments included: Q „. w - <br /> Busines&Rep"` Signature Phone Number Inspector's Signature Phone Number <br /> e 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X jl� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> L <br />