Laserfiche WebLink
:_. Waste Tire Sum & Inspection Repor spectionReportNumber _ <br /> GCIIl State of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 i 5 - 10 1 0 6 4 61 <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details Ar <br /> TPID- !! 2 Inspection Type (Fill one) <br />} Site Suffix: i 1 D , 7 U I (� Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local '1 ) If Referral,choose referral type(Fill one) <br /> Identifier: ( lit n tit Vj 10 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name ( — Inspected By Inspector <br /> Physical'Address Lil—C - I f LC <br /> �,Kr t,_ k,-," i <br /> I <br /> Inspection Date <br /> / I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title Q AM=OAM <br /> O PM m O PM <br /> Operational Status Tire Type—7 Business Role torage Type <br /> O (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Count(Whale/PT <br /> zo <br /> (0Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude - 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> "Longitude 0 Planned OTR' End-Use 0 Container <br /> _ <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other ! l <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> - ---- - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 M / M / 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: § 1 / y/ j t <br /> CommentsG..' 0 �n J.(/�.{ le 1^j1 �r PW iillco 400ry 9 <br /> Inspection Form Included: <br /> Comments Included: 0. <br /> Business Rep's Signature Phone Number Inspector's Signature - Phone Number <br /> ' <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X _,' 1., F f 62081 <br /> 2 ' <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />