Laserfiche WebLink
:::: Waste Tire Su&y & Inspection Report Inspection Report Number ■ <br /> ii2 State B California Survey Form - Page 1 f S f V V Y V' 1 <br /> CIWMB 181(New 04/04) I <br /> California Integrated Waste Management Board - - - --- --- ------+ <br /> Part A- Survey <br /> p BLUE OR BLACK INK PEN <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I o �� C!; D - L � Routine 0 Re-inspection 0 Referral 0 Observation <br /> II <br /> Local r^ ^I If Referral,choose referral type(Fill one) <br /> Identifier: `.t rt ��jC�'' f L1vw { :^ v f ' i 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility NameU. <br /> Inspected By Inspector <br /> Physical Address -2� - J ' �( 6 V"•: ,. r <br /> 00 <br /> Street <br /> _ Inspection Dateyl <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM O AM <br /> J : �[_� <br /> � ` PM J PM <br /> O(6c Ce II Viiit <br /> Operational Status 7t ) r iF a'I Business Role Storage Type <br /> (Fillone only) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Generator 0 Outdoor <br /> Latitude <br /> O 0 Closed (�1� t °t('�i�M`i <br /> GPS m . 0 Hauler 0 Indoor <br /> o 0 Inactive <br /> Longitude F <br /> 0 Planned 0 OTR 0 End-Use 0 Container <br /> BUSInLSS' '^ <br /> ___—_ ..:j+,. _:,s.y,..r �.'8���...a1:.,.,�h,h.,'w„"4,zua:5„~U,',.rpq Wfln.�t`,u ,”�ai�'"4,r4 '& ,.a',h1?�r• :k; ;rJd%%J'"`; .,,✓"t'.p "..✓M.s,* J .h3�ak, ?A"`anwr�'""_tia'?, t:r3 c,A,r; ,i ru ice__ ,.M1�.�,i, <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber r <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (a Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A rPRC 42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> HAULING AND MANIFEST REQUIREMENTS <br /> 0 O § g p <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date mm m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments kb to Y _( 1�' C f!'J r l !_4, - r r':("f �� ��l�C l�J" Wo S Yl 15 C- <br /> t1 ��' 1 l li tir,I ` ( /ti <br /> c-':) .�• GL- ; ., I t ��� J� � rt in t 1 ✓Cti P I r� � yt� t4-it, e_141- <br /> Inspection <br /> 4 -Inspection Form Included: 01 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: A All. l_ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />