Laserfiche WebLink
-------- ------ ----- - -Wast --------- <br /> e Tire Survey & Inspection Report Inspection Report Number <br /> ■ <br /> `iTklil State of California 1144028 <br /> am CIWMB 181(New 04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK-PEN <br /> t A- Survey --Tinspection-Details <br /> ,siness Profile <br /> Inspection Type (Fill one) <br /> TPID- 61 C, - <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localif Referral,choose referral type(Fill one) <br /> Identifier: sa A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or—Facility Name Inspected By Inspector <br /> 6 A6C, Sjppt� eury►PC,cav <br /> Physical Address C) /+yzvn <br /> 41,5544 Z­ckvi(f, Inspection Date 4q o), -7 <br /> 6A 9-tQo(o Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> 0 0 PM 0 PM <br /> 0 Operational Status' Tire Type Business Role Storage Type <br /> eirati <br /> ( 110p y 11 that ply) <br /> p 111that <br /> p <br /> Fill one only) (Fill all that apply) (FillallhI (Fill a ap <br /> Tire Count(Whole/PTE) 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altered 1114 /y/A <br /> GPS Latitude i 0 inactive 0 Truc eVIA 0 Hauler 0 Indoor <br /> 0 <br /> Longitude 0Planned 0 OTR 0 End-Use 0 container <br /> isiness Type (Fill all that apply) <br /> - Fleet 0 Government New Tire Dealer (�i Auto Repair 0 Trucking 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 (D Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - <br /> IV <br /> VI A I HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 1 0 1 PRC§42956-Registration/Decal in Vehicle <br /> 1 / / <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Ellm <br /> 0 01 m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 /> Other: § <br /> 0 0� <br /> Comments C 1 ��f 7 z,-y <br /> kx r-6� A i)jr IL&A ey An?e, <br /> PCXA) o Pr- <br /> �- ( -- <br /> C),,nWj40 4p C <br /> Inspection Form Included: 0 <br /> Comments Included: 0. <br /> Business Rep's Signature Phone Number I' t lgnatu!4)" Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 62081 <br /> X A.M. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />