Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> State of California 11 - 1143494 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACKINK PEN <br /> Part A- Survey_ <br /> - - -- <br /> Business Profile Inspection Details <br /> TPID- I u Inspection Type (Fill one) <br /> Site Suffix: 1 W 1 O I Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local <br /> r If Referral,choose referral type(Fill one) <br /> Identifier: �(�{� �QL(Q ul Il `UL��� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 5 A_ �Q� Csr`v�' <br /> Physical Address <br /> Inspection Date I 3 I <br /> �U C� Time In Time Out <br /> AM O AM <br /> Business Rep Title U ` <br /> 1 3 0 PM l J B PM <br /> �uu laS bA'I ICA Qus --- Storage- - <br /> Operational Status Tire Type Business Rolle <br /> Tire Count(Whole/PTE) rage Type <br /> (Fill one only) (Fill all that apply) Fill all that apply) (Fill all that apply) <br /> r <br /> — � Active 0 Passenger ® Generator Outdoor <br /> 0 0 Closed 0 Altered ' <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 Inactive ® Truck <br /> 0 <br /> Longitude — 0 Planned 0 OTR End Use Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer 0 Auto Repair Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 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 /> V A HAULING AND Mt�NIFEST Registration <br /> REQUIREMENTS <br /> Transport of Tires 0 Notice Of Violation 0 Extension <br /> PRC <br /> 0 01 § <br /> 0 . 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 li PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> 0 I 0 <br /> 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> - <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 I 0 Other: § <br /> r 1 <br /> Comments LIP . 0. _ l�� `n i cL� 4S a� ] t JIG {1 V1 <br /> - - '��U �v,��.�►,��ns �,r U��e,.�_� �c�n cern <br /> Inspection Form Included: 0 � <br /> Comments Included: O Plignalure I seVsSign/atur * <br /> �JPhone Number <br /> Business Phone Number p62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X . 1 I E� :�I White Copy:CIWMB Yellow Copy:Operator Pink �� ■ <br />