Laserfiche WebLink
■ Waste Tire S_.a .ey & Inspection Repc . _ Inspection Report Number ■ <br /> 'i33I State of California <br /> 't CIWMB 181(New 04/04) Survey Form - Page 1 I 1 - 1144033 <br /> California Integrated Waste Management Board <br /> P'rtA- Survey BLUE OR BLACK INK PEN <br /> iness Profile - _- - -- - Inspection Details - <br /> eID- - Inspection Type (Fill one) <br /> Site Suffix: .� V 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local y� / If Referral,choose referral type(Fill one) <br /> Identifier: �\ c_ liV1 V` ' 1� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name 111 Inspected By Inspector <br /> C c.►'�.cr�— Gil c' �Sfzn�: `3 C� - <br /> Physical Address <br /> -75-7 r1offc f 1 crvlevetr� -- <br /> 6A <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep {— Tittle O AM ^� O AM <br /> a PM 10 PM <br /> - - — -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ?,(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> -- - O ® Closed 0 Altered <br /> GPS Latitude A11A 0 Hauler 0 Indoor �7 <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 /> V ' A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 j 0 Notice Of Violation 0 Extension <br /> 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 /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> I <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: § <br /> Comments <br /> ,pection Form Included: 6 <br /> Comments Included: ® --- -- - C <br /> -Busin e se Phone Number fins t 's i ature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ! (1kV tt J6� P I� ej T 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />