Laserfiche WebLink
• :"• �8i84050008 <br /> ev. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> eOfemla Su <br /> CWMB l rve 1 MIMB 181(New 01/04) Y <br /> Form - Page 1 8 1 0 7 9 2 9 6 <br /> Califomla Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / •� TI Inspection Type (Fill one) <br /> Site Suffix: I / I_� V / •F I �Q� FoT l <br /> _111_�I *Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> ^py If Referral,choose referral type(Fill one) <br /> V <br /> Identifier: �/�„j T.^ ", . 6r Q CHP Q CIWMB Q.Complaint' Q Educational Visit Q Other <br /> Business'or Facility Name U ` Inspected By Inspector <br /> l_ <br /> Physical Andress / - / D / J�,t f4AADUQ <br /> Street <br /> �A} 64 n 1220 Inspection Date U <br /> City" 'C �O 9tauttw ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM m' <br /> EEI <br /> QPM <br /> is rj W�rtA{t��' ,I d ce- �•(Ea�. <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f r Q go (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> .0 Closed Q Altered <br /> Latitude � <br /> GPS •Hauler 0 Indoor <br /> L <br /> - - —:0 Q Inactive Q Truck <br /> Longitude - 1 9 End-Use Container <br /> I i I Q Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair Q Trucking Fleet O Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> Q Service Station 0 Hauler O Agriculture Q Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS 7 r <br /> V A HAULING ND MANIF.iIIEST R-QUIREMENTS <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required/or NOV or FX>) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/GIWMB 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 In Compliance - No Violations <br /> Q O Other: § <br /> Comments <br /> --or��►iJf,--/%JSPe��' S/Ix__�v_c/a.'�G_.-�6e"-L�lo+,u•;�9 cd�.o- �� <br /> %�«`• <br /> 4- <br /> Inspection <br /> Inspection Form Included: C <br /> Comments Included:Q �Cl� •� <br /> Business Rep's ature Phone Number Inspector's Signature one Number <br /> INSTRUCTIONS ON BACK C•nest ncorreet. X A M P L ! ji[2131 62081 <br /> ■ White Cop:CIW Yellow Copy Operator Pink Copy.LEA ® ■ <br />