Laserfiche WebLink
Waste Tire Sur „ay & Inspection Report Inspection Report Number ■ <br /> 18;x, State California I 1 - 1144002 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details - <br /> TPID- *� u Inspection Type (Fill one) <br /> Site Suffix: 1 t $ - 1 O I Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> 1 <br /> Identifier: (�(� J �C L(1 r\ GX Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 0u(Ick a nspas�s &0e a <br /> Physical Address <br /> '15-20S <br /> G _r Inspection Date 5 / I I 0 <br /> JJU (.(, D CA J (S Time In Time Out <br /> Business Rep Title ,�,,�+ 1 ' � 5 0 AM � � � 5 0 AM <br /> 0 PMSPM <br /> Ni-v <br /> p Type <br /> Fill all that apply) Storage Type <br /> --- <br /> Operational Status Tire T e Business Role <br /> ' (Fill one only) (Fill all that apply)I ( pp y) (Fill all that apply) <br /> Tire Count (Whole/PTE) 9 , <br /> Active ® Passenger I ® Generator i ® Outdoor <br /> PS Latitude Q Closed Q Altered Q Hauler Q Indoor <br /> G <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q 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 Is Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date© / l <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB a / M16) <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) - <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> to Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § --- --- <br /> Comments RILLJGI1, loved s1L-USa �S � C w ng WGI� b C r <br /> J- v i �GIT� ILC �-1061 C� LS 0C1 1 ►LQ� �O-J M-131; 1q Aak"CS G VL <br /> J <br /> 1 __II'' f� '�[f�f( ►'''] it <br /> Inspection Form Included: Q `���� • (���jM 1��1 1 l`UV-�I /� - <br /> Comments Included: • oo <br /> BusiSi nature Phone Number Inspe ors Signatadure <br /> Phone Number <br /> - --- ---- --- Y 1 � �: f� M � � 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X <br /> ■ White - --- - ® ■ <br /> Copy:CIWMB Yellow Copy:Operator Pink Co y: <br />