Laserfiche WebLink
Waste Tire SAby & Inspection Re or Inspection Report Number <br /> p <br /> State of California - .... +� _... ,{`. _....._ . ...._., _-..-___.. ■ <br /> C WMB 181 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 yJ { V Ai{ 06 6 2 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> n•r� �� pa� "� �tV�tp r�'� -- ��,� t'�f�"`br�"'f�u' dL�""1M� �"r � f'rf ,N�,�^ i '^� �C'�„�Mi���''���"��f�*"5 <br /> ala� �"r ��fr..�ra��f',.3r"���'.:�.��'�..v.d��'":w _�!�.�;WM"xf.s �:�o✓,. fWa�,w�"��m�.f � ��'�+: <br /> 7s <br /> TPID- I-� Inspection Type (Fill one) <br /> Site Suff <br /> V Routine O Re-inspection O Referral O Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: _f// jr- f . �.t ' O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name i ) <br /> ' Inspected By Inspector <br /> Physical Address <br /> JO <br /> Street <br /> ' Inspection Date 2 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title _U0AM <br /> 0 AM <br /> rl ,' QPM [:E <br /> ' � QPM <br /> Operational Status arm ,r� g`�,°yrr'" Business Role <br /> �" ,t nr� <br /> el", <br /> (Fill one only) ( t(�� ��� (Fill all that apply)1E :1E <br /> l.' ha <br /> Active �w��R , e d� f (D Generator t to <br /> 0 �, r� "v ,`�r of��a`t„�✓m N� <br /> G PS Latitude O Closed <br /> O h" r� O Hauler <br /> O Inactive rw �. <br /> Longitude — O PlannedibX O End-Use i <br /> O New Tire Dealer O Auto Repair O Trucking Fleet ® Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder 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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires O Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire HaulersQ Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O O Other: § <br /> Comments / JI <br /> 1(/(�_, ; 1 l <br /> +' ��lf , 1 �� l., <br /> l a, �� �a <br /> kt�f ' #� > c tl C>ft{�Cf 1 I'! :' j �(r <br /> Lel 06 rJ jc 1r5 t rf tf �. �.�.r (�11 Is"�✓rr 4' �,. +{ .) 1� �s �(,7 f: -'� <br /> US�t'MeS <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ,. o 62081 <br /> _ _— - <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />