Laserfiche WebLink
Waste Tire Su4k*y & Inspection Reporlelnspection Report"Number <br /> w a:... State of California I7 <br /> m� CIWMB181(New04/04) Survey Form - Page 1 I �, `F <br /> California Integrated Waste Management Board a e- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile —J Ipspec#ion.De#ails -- -- — <br /> Inspection Type(Fill one) <br /> Site Suffix j y) � L! Q1 1( ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local ( 1 t If Referral,choose referral type(Fill one) <br /> Identifier: I +JI:1, � r� ;�,(,.� L,L;: t. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name i Inspected By Inspector <br /> k <br /> ' <br /> LA <br /> Physical Addr —� <br /> ai L. 'l � <br /> Street f �; Inspection Date Ti <br /> Cfly sh2f l!R Code. Time In ime ut <br /> Business Rep Title {{/ �0 AM gg 0 AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type ` Business Role Storage Type,"� <br /> (Fill one only) (Fill all that apply) (fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE),y r <br /> Active 0 Passenger Q Generator 0 Outdoor <br /> C 0 Closed 0 Altered <br /> GPS Latitude ��1 ,LLL -Li j 0 Hauler 0 Indoor <br /> ( -- — I 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 /> - EMEN <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS �I <br /> V A 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 /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 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 Q In Compliance - No Violations <br /> 0 0 Other: § <br /> ` Comments <br /> } <br /> I <br /> y <br /> -— <br /> 1 .. Yi Pi tt� 1 <br /> T, r ti C - C (�tC���: a1 "V �1� f Si/ tirl <br /> Inspection Form Included: 0 � <br /> Comments Included: 0 <br /> Business Rep's c p <br /> Signature Phone Number inspector's Signature Phone Number <br /> d , <br /> INSTRUCTIONS ON BACK Correct:.® Incorrect: X � '. �, Al., t; I. `.i_ 62081�.a <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> p <br />