Laserfiche WebLink
'�- U91R2flA0213 <br /> -E18 Waste Tire Survey & InspectionReport Inspection Report Number ■ <br /> LE State B 81(Now Survey Form Page 1F-II - 110846 <br /> CIWMB 181(New 04/04) Y � ry <br /> California Integrated Waste Management Board y _ <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I Q �- I Inspection Type (Fill one) <br /> Site Suffix: l I (� ; 5 a �� CI`_J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local _ / If Referral,choose referral type(Fill one) <br /> Identifier: n_ alL-AUX / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v, <br /> h� 5 Cpm Qu �_L LCInspected By Inspector <br /> � <br /> - l o - <br /> _'J31_E M_an- c)s� f�. I r� <br /> aInspection Date <br /> city <br /> v L-1-t-1-V`-1 Sime �IP C�_ b <br /> Time In Time Out <br /> Business Rep Title i - Q AM r -1 Q AM <br /> PM OPM <br /> _&bef " . _Kam .- — -.. ?. nJirC>n►►te> -- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fin one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> f f I&Active Q Passenger Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude O Hauler O Indoor <br /> -- -- - - - O O Inactive ®Truck <br /> Longitude - O Planned Q OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair ®Trucking Fleet 0 Government 0 Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other I <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCE-MENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Natice of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> O Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days Req i N V•r <br /> O Q 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/C-IWMB Enforc nt <br /> O Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® n Compliance No VI latio IS <br /> Q 1 Q Other: §__ <br /> Comments <br /> \ <br /> Inspection Form Included: Q <br /> Comments Included: Q � <br /> Business Rep' Sign lure Phone Number ns c r' na re Phone Number <br /> INSTRUCTIONS ON BACK C rrect: 1 correct: 62081 <br /> E X >a11AP :L E' 1 ;2 3 <br /> Whit-77? <br /> hite C y.CIW Yellow Copy:Operator Pink Copy:LEA ® 0 <br />