Laserfiche WebLink
Waste Tire Sulay & Inspection ReportQ�nspection Report Number <br /> State of California - ; ' _ A A <br /> 5d CIWM8181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> IPart A Survey BLUE OR BLACK INK PEN <br /> QWStr1 55 T�pi le t <br /> 5, / z IttS e�1t1 1t ll�$di s 5 <br /> ! <br /> Inspection Type (Fill one) <br /> i Site Suffix �_ <br /> lr Q Routine Q Re-inspection Q Referral <br /> TPID- Q Observation <br /> Local f I If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> L r <br /> Street r, <br /> J Inspection Date <br /> Cit i ( 1 Stat I lf <br /> e ;�jp Code Time In _ Time Out <br /> Business Rep Title AM AM <br /> + _^ O PM �� � O PM f <br /> Operational Status I 'Type Business Role <br /> (Fill one only ill all that apply), (Fill all that apply) <br /> Tire C ilunt,(Wla ►le/PTS <br /> Active `�Q�)'as&engr�r �� Q Generator <br /> Latitude C Q Closed �Q Alter'ed <br /> GPS _L_ _ a Q Hauler <br /> Q Inactive „T1uck <br /> Longitude iQ Planned <br /> » . a Q End-Use 11 <br /> Buslnes`��lyp �Flil a�"th�ap <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 Q Other , <br /> _ nl, <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q 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 /> 14 CR§ . - re Program ID Number from CIWMB m m <br /> C184591 TiP <br /> m <br /> Q Q I � <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 'II 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 <br /> Q In Compliance No Violations <br /> Q Q Other: <br /> Comments r{'. <br /> Inspection Form Included, Q� <br /> Q ... <br /> m <br /> Coments Included. — f '•, _ � ' .. <br /> Business Rep`s, Signature ✓�— PhoneNurnber . w- InsFectorSignature Phone Number <br /> - -- ---- _ <br /> -- �—� <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: 62081 <br /> ' ': 4 <_ <br /> 1 1 1-- 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />