Laserfiche WebLink
Waste Tire Su&y & Inspection Report Inspection Report Number ■ <br /> State of California 3006 .i <br /> ? !It <br /> L88.6fl CIWMB 181 New 04/04) Survey Form - Page 1 �� 6 - .1 01 J 0 0 D <br /> California Integrated Waste Management Board -- --- - -- <br /> Part A Survef BLUE OR BLACK INK PEN <br /> {rt{��r { �>/rz/ / ° .��{ { x <br />{ TPID- r_. n / Inspection Type (Fill one) <br /> Site Suffix: jj�� ) / r. - <br /> �� V / � f J V outine � Re-inspection Q Referral Q Observation <br /> Local if�r f Referral,choose referral type(Fill one) <br /> Identifier: .-v't i O� L•„trl Ltil Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> respected By Inspector <br /> L �t�Qlr l:la✓ V Vl l�, I/Y C1✓'i(< <br /> Physical Address ,' ( + / t✓jlt .,,(.<'�� <br /> Sfreet , 'a1 �� ! _/ Inspection Date QT / F—T <br /> Cit J/ '; State ZIp Code Time In Time Out <br /> Bmess Rep (� Title --4 , _] , . ,m PM <br /> M <br /> Operational Status Tire Type Business Role Stora rr wl `r t <br /> Tire Count(VilhOle(PTE} ' (Fill one only) (Fill all that apply), (Fill all that apply) (Fill aifU m , l ' r)+� <br /> ill ,� � �'a�t (Z) Active Q Passenger Q Generator Q 0 <br /> r <br /> m � Q Closed Q Altered <br /> GpS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Tfucic { <br /> Longitude Q Planned QOTRQ 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 /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ° 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 —- 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 /> 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q,\Q 14 CCR§ 18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 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 Q In Compliance - No Violations <br /> Q O Other: § <br /> �Cl Lie �.; �. <br /> Comments ltttt 'LC vl�f Ir �r �n <br /> G Iic O rpS, <br /> //Gt <br /> -jo _. �. M �. ` > !' / r �' --� _,, �. f,�`,�'��� `f`/ - f_ `� L.t-! S y7 CSL! �a` <br /> Inspection Form Included: Q <br /> a <br /> r <br /> Comments Included: Q - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> �r� 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X ”` �s� 1. 1 _ <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />