Laserfiche WebLink
Inspection Report Number <br /> � Waste Tire Su. .ay & Inspection Repori� p p <br /> State of California <br /> CIWMB 181(New 04/04) <br /> Survey Form - Page 1 i - 10 0 6 t' J <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection.� `� � � � - � ; Inspection Type (Fill one) <br /> Site Suffix: b 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: CL V" V" �' V-^v 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility NameInspectorBy Inspector <br /> Physical Address D <br /> �[��- ( Inspection Date <br /> ��� Time In \ Time Out <br /> Business Rep TitleXy _ Q AM 0 AM <br /> � l <br /> AV\ V-, <br /> Operational Status Tire Type Business Role Storage Type <br /> r (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 7 t � J <br /> Active W Passenger ® Generator QO Outdoor <br /> = 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 8 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body W Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> IQ 0 <br /> i0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§ 18459 - Responsible Entities Complying with Manifesting Requirements Date 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 EX7J <br /> ------- - <br /> 0 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> - - - -- - — <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 ® In Compliance - No Violations <br /> 0 0 Other. § <br /> Comments (iV� <br /> �- <br /> LLz > ��.�c-� -� t • --r- <br /> L2_ <br /> �Lc1(fc' 1 (AQA C <br /> l vk <br /> Inspection Form Included: 0 <br /> Loi ZV- 7777 <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number In tor's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X 1�, C. A �,�,I P L1,II_'9 l�� 62081 <br /> ® White Copy OW ME Yellow Copy 0.erator Pink Copy:LEA <br />