Laserfiche WebLink
ns Inspection Report Number <br /> Waste Tire SuRey & Inspection Report <br /> rr State of California I .L 1088321 <br /> CIWMB181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> A- Survey <br /> iness Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` p�C Q ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ /_' If Referral,choose referral type(Fill one) <br /> Identifier: J '�t" c.C1t�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> Physical Addres% <br /> � <br /> / 1 Inspection Date `J 1 l C) <br /> C',E� `5v``f 0 Time In Time Out <br /> Business Rep Title n AM <br /> 49 PM +7`- ®PM <br /> LTJ12LYI U 'USF-�� i <br /> Operational Status7Tir, Business 700utdoor <br /> e <br /> (Fill one only) (Fill all that pply) <br /> Tire Count(Whole/PTE) Q Active ®GenerO ® Closed '4GPS Latitude Q Hauler <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Rusiness 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 /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ,n <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ; A HAULING AND MANIFEST REQUIREMENTS Q 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date FP / M / R] <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOVor FX!) <br /> Q Q -- <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Other: <br /> Comments <br /> Inspection Form Included: Q l� V <br /> Comments Included: — ct is i nature Phone Number <br /> si es Rep's Signature Phone Number n P <br /> - — --- �-,� 62081 <br /> [CorrectINSTRUCTIONS ON BACK Incorrect: X � f4 LIE] 1112131 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />