Laserfiche WebLink
ii f <br /> ■ Waste Tire Sui .ey & Inspection Repor. Inspection Report Number ■ <br /> State of California <br /> CIWMB 181(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 Il - 1127912 <br /> Part A- Survey_ _ _ BLUE OR BLACK_ _INK PEN <br /> Business Profile rInspection Details <br /> TPID- ` T � `► � r � _ Q � Inspection Type (Fill one) <br /> Site Suffix: 1 (� , `Q Q Routine Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: s(ko �C�C.1��1111n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 - I Q � <br /> \-A% )C' C\)'oAe_r �p <br /> Sho�&o CA %aInspection Date <br /> te � <br /> Time In Time Out <br /> Business Rep <br /> , Title 0 AM 0 AM <br /> Ala �US� \t\p nUr'(L(4QS -� � � 4) PM � � U � PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) c� l (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> d 1 !Active ® Passenger s Generator Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler � Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End Use Q container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V FA IHAULING AND MANIFEST REQUIREMENTS <br /> 1 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 /> M / m / m <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 /> _. _ -- <br /> 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 Q Other: § <br /> Comments <br /> U�W. 1�vCf,�l - 1- - - -- <br /> iInspection Form Included: <br /> Comments Included:® <br /> B s Rep's Signat re Phone Number Inspe is Sign ure Phone Number <br /> - - - --- 62081 <br /> : <br /> INSTRUCTIONS ON BACK Correctcorrect. X �[ P f 3 <br /> - - <br /> White Copy:CIWMB Yellow <br /> Copy:Operator Pink 0op A ■ <br />