Laserfiche WebLink
opo ytenn�e <br /> +o�37oavv� � <br /> Waste Tire Survey & Inspection Report Inspection Report NumberState . <br /> err. <br /> ar; ClWM 181(N.. Survey Form Page 1 I 1 10 8 8 3 9 6 <br /> CIWMB 181(New 04!04) <br /> California Integrated Waste Management Board y I <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- F/Tq � Of� Q rInspection Type (Fill one) <br /> Site Suffix: l l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �^ If Referral,choose referral type(Fill one) <br /> Identifier: J�a __ _ _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name UInspected By Inspector <br /> LatmPhys! Addr a <br /> L I&DD CoYrat.Q (� y 1 _ <br /> Street Fn <br /> 7-8-/� <br /> Inspection Date / 1 9 <br /> JState LiP CCt P.) Time In l/ Time Out _ <br /> Business <br /> /IRep J Title F� �—'—�t�AM r, — O AM <br /> ru <br /> OPM <br /> t. <br /> -- '010 Storage perational 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 /> D IIs Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q PlannedI OTR Q End-Use ®Container <br /> Business Type (Fill all that apply) 1714,1 <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®Government Q Retreader ID 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 ®Other L_f 'R� <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! 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. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 EXTJ <br /> Q ® 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I C-IWMB 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 1 Q 1 Other: § <br /> Comments M--L:.-„ u„c f n_ qr_ y� `c „A_,F,, �, c -yj 1 i_ /IT <br /> nIAwLFe,S� (11St�1r��iwv1 C��t,� �Ui w r�—✓D,I� _ o.Y_111C�1 - <br /> �lo`tQr es ►� a c� It7- . <br /> F � � - - ?.� � sem. <br /> Inspection Form Included:Q11AC, . <br /> Comments Included: <br /> Business Rep's Sign ure Phone Number Inspecto Signa ure Phone Number <br /> INSTRUCTIONS ON BACK Correceorreet: E X A P L E' 1 2 3 szos, <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> I <br />