Laserfiche WebLink
Waste Tire S%e & Inspection Re ^ Inspection Report Number <br /> -e� Y p p <br /> State of California <br /> CIWMB181(New 04104) Survey Form - Page 1 I1 - 1143712 <br /> California Integrated Waste Management Board <br /> Part A- Survey _-_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> � TPID- � � � 6 / �/' � - © I Inspection Type (Fill one) <br /> Site Suffix: /v, 1`Ln� D Q Routine Re-inspection Q Referral Q Observation <br /> Local ^ If Referral,choose referral type(Fill one) <br /> Identifier: Say JOmgLI.1t n (OkALi Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name �� Inspected By Inspector <br /> ���c� C�Vc� 3 °l - 0 <br /> Physical Address l <br /> k4l,2 9_�C4,)4 _Vj&,LA <br /> U IS3au Inspection Date I e I I 1 b <br /> Time In lVY' Time Out <br /> Business Rep TitleO AM O AM <br /> O 0 P O SPM <br /> �' - - - - -- Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 10 Active 16 Passenger Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler 10 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 /> Q 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 & 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 /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> 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 /> Q Q .14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q i 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 EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> i <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 <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> O j Q Other: § <br /> I � 1 <br /> Comments SCJ\0lj�n -— C) _� I �d . 1�)J 1 <br /> � 1 r <br /> ,Inspection Form Included: OI U <br /> Comments Included: QI - <br /> iness p's Signature Phone Number Inspe is Signature Phone Number <br /> / �i hl� F L �'' 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: t �_/ E X111213 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />