Laserfiche WebLink
=L �� Waste Tire Sy & Inspection Repo Inspection Report Number <br /> Sate of California <br /> CIWMB 181(New 04/04) Survey Form - Page 1 - 1 0i061 51 <br /> California Integrated Waste Management Board - - - -.. <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' Inspection Type (Fill one) <br /> Site Suffix: I ' I % �/ rr - �� <br /> Q Routine Q Re-inspection Q Referral Q Observation 1 <br /> Local " <br /> If Referral,choose referral type(Fill one) <br /> Identifier: , '{ l✓ C.�Uv1. alt y,l" O CHP 0 CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility N:—ame 0 Inspected By Inspector <br /> 0 � � <br /> Physical Address <br /> Strdet 1 <br /> rL/ t �_ �✓ Inspection Date <br /> Citv State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> E7 0 PM 0 P%'I <br /> I I�f Y,;( I -,1.�rpt'I' I't <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PT / (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> E <br /> a Active 0 Passenger O Generator O Outdoor <br /> I� FF1 O Q Closed 0 Altered <br /> GPS Latitude O Hauler 0 Indoor <br /> O 0 Inactive Q Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use Q Container <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet (S Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station 0 Hauler Q Agriculture Q Shredder Q Other <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 /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O 1 O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB 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 O In Compliance - No Violations <br /> O 0 (Other: § <br /> 1{ <br /> Comments I fYi a. ( ( /V1.4 S i'`� .( �(��1 %li .fir J fC t � .t .f <br /> cIc`t +: lC oto Tire JLY AyiCk4SC C.twd V rec,d j:✓ oiCCC1 Y, <br /> / c: <br /> vtl <br /> Inspection Form Included: <br /> Comments Included: <br /> j Business Rep's Signature Phone Number Inspector's_Siggature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X lx A iTj P L L, 11 I L 16 6201 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />