Laserfiche WebLink
�'' Waste Tire SpOey & Inspection Report. ,Inspection Report Number ■ <br /> W C State of California + I <br /> ® CIWMB 181(New 04/04) survey Form - Page 1 0 3 4 <br /> California Integrated Waste Management Board J ---- <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> r r r r nr. <br /> �������"����• , r►•Detalts <br /> TPID_ Inspection Type (Fill one) <br /> Site Suffix: F I f� �1 ✓ � T; <br /> Routine Q Re-inspection Q Referral Q Observation <br /> Local y If Referral,choose referral type(Fill one) <br /> Identifier: (�� �l(a '�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> _ _ o�Physical Address —_r , .. - ' <br /> Vo <br /> Street Inspection Date <br /> City State ZIP Code Time In Time Out 0 AM <br /> Business Rep \ Title 0 AM <br /> O PM . �— O PM <br /> 40� Y rl Ir, F 1111 �I t(1r ';' I - r, <br /> aw PP I „ kl Operational Status w E a �, i' r Business Role Storage Type <br /> (Fill one only) j (F� c" Itlg (Fill all that apply) (Fill all that apply) <br /> �1 Active ) rvA (Z) Generator Q Outdoor <br /> - i JmJ rr k t . xys, t,,,: <br /> - p Q Closed <br /> GPS LatitudeLLLI tr��a "tt � � r�J Q Hauler Q Indoor <br /> Q Inactive , <br /> Longitude - f 0 <br /> Lon <br /> 9 End-Use Q Container Planned tr <br /> I r t re ;iaf r r s„til rent+Vi t.raa"w µt lrrrik f tt <br /> � r <br /> Q New Tire Dealer -Q Auto Repair 0 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 /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - - <br /> V A''i 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 /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required,for NOV or EXT) <br /> Q O <br /> 14 CCR§ 18459.3-Retention of Manifest Forms and Tire 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> �v+ {I'�� r'! <br /> -j4•01 <br /> �JU ✓ I�> I `^ ! ��%+ �� :;�t�G {yP 1 i t_ <br /> I � <br /> 62081 <br /> INSTRUCTIONS ON BACK I � � , y �� ' A 1112 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />