Laserfiche WebLink
s. <br /> Waste Tire ,.urvey & Inspection Rep_ _ t Inspection Report Number ■ <br /> State of California Il - 1140837 <br /> CIWMB 181(New 04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> 'A- Survey --__ BLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> iVID- <br /> rel Inspection Type (Fill one) <br /> Site Suffix: l-J l-1• Routine Q Re-inspection Q Referral Q Observation <br /> Local /' If Referral,choose referral type(Fill one) <br /> Identifier: V�� Col/✓, Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business orr,Facility Name Inspected By Inspector <br /> �kl <br /> s� IVe� <br /> PhysicalAddress s J <br /> `� 1 � C) L T-1 `I7�JfJG /TIGIIYI <br /> Inspection Date 1 I / ] <br /> CA q,5o?a L e✓ l <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> t Z ® PM l Z_ PM <br /> Jim Ul�sc-� &Uemcd 1°1- — - - - <br /> -- - ----- -- ----- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � f <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered / tv lA- <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> .i 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 ®Other - G�JAa,i kvtz c— <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q 10 Notice Of Violation Q Extension <br /> 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 /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX7) <br /> Q O - -- - <br /> 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities j <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> C� <br /> ,..�pection Form Included: Q <br /> Comments Included: �l `\e`�`MV 1+J�3�Oc� v?G� 6S Yb <br /> Business Rep's Signature Phone Number n p tor's gnature Phone Number <br /> - - - --- --- --- - -- -- -- - - <br /> - -- _ -, <br /> 2081 <br /> INSTRUCTIONS ON BACK Correct.6 Incorrect: X 6 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />