Laserfiche WebLink
F11 <br /> Waste Tire Su loy & Inspection Repo Inspection Report Number <br /> State 1 <br /> CIWMB181California Survey Form Page 1 f 6 0 2 7 <br /> CIWMB 181(New 04104) � <br /> California Integrated Waste Management Board <br /> 1 1 <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I&Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> PhTys2 Address <br /> 1 n7 Z O S.&Oa - <br /> � � � Inspection Date 3 / D �+ 157 <br /> l Time In Time Out <br /> Business Rep Title - O AM O AM <br /> O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)' <br /> 1 Q Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude - Q Hauler Q Indoor <br /> o Q Inactive Q Truck <br /> Longitude — Q Planned i Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair S Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> Y A I'tA4ULING Aiti!MANfREBT REC1UItSM1YS <br /> Q Q Q Notice Of Violation Q Extenslon <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Cgmphanco DesdRne <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q ! 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements pate <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB j <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days - (R6qulred for NOV orEXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers C kifili4d .CIVYMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q i 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> tiRotixlFile�Cot No-YSQletfon• <br /> Q Q Other: § I <br /> Comments <br /> 7 -r5 <br /> C, <br /> f S n' Ao4r-- <br /> Aew4lli" / . <br /> �, <br /> Inspection Form Included: Q <br /> Comments Included: Q !'\ � <br /> Busl s Rep's Signa a Phone umbeer�rP Phone Number <br /> INSTRUCTIONS ON BACK G�# _ .�I��4 #� NZ F ' frit„M1 R LLK1-I 62081 <br /> Whit.Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />