Laserfiche WebLink
- 0812905U049 <br /> Waste Tire Survey 8InspectionReport Inspection Report Num <br /> ber <br /> araaelc.�rm.. ■ <br /> Survey Form Page 1 12 - 1 0 7 3 _4 3 4 <br /> CIWMB W (Neweuoel <br /> Cali/omla IntapnlW Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / O Inspection Type (Fill one) <br /> Site Suffix: �J "( - Routine Re-ins { <br /> ® Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identlfler. �Oe _ C(�l.r'LI}f Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name —LV-L <br /> Inspected By Inspector <br /> �,iA <br /> Physical Address <br /> Street <br /> LS)V C/ Inspection Date <br /> City �( State ZIP Code Time In 1 Time Out <br /> Business Rep Title 0 AM 0 AM <br /> O PM O PM <br /> mcg v►dog (�„ op s. — — - <br /> �I - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) O <br /> r I ®Active Q Passenger ®Generator Q Outdoor <br /> - 0 Q Closed Q Altered /�l <br /> GPS Latitude -I- I I —� J Q Hauler Q indoor <br /> i <br /> O Q Inactive ®Truck <br /> Longitude - I I I F Q planned ®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 Dismander Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber ty^'pyt�D <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT STgTUS <br /> V A HAU LEING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Exten ion <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-omplianc Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <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 <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 11CReferred!CIWMB Enforcement <br /> I <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> QQ 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® Compliance No Violations <br /> Q Q Other: § <br /> i <br /> Comments Qv.,. I„C,���,� � n p a oil- <br /> btSCS �i W Lr�x �1 lar+wt�rlr_ t� -}lam —✓_L 0— <br /> ViA <br /> 6 <br /> tf� art �/0 ��led C�ucer�¢g {U� Sca - ren aV_ <br /> IF <br /> JoW :VgkAa'� 0-4r � Wv__ 01 o _�1� qz <br /> Inspection Form Included:Q <br /> Comments Included:® %0o 0- <br /> Business Rep's Signa re Phone Number Inspector gnature Phone Number <br /> INSTRUCTIONS ON BACK IEIXIAIMIPILIEI 1112131 <br /> 62081 <br /> . White Copy CIWMB yellow Copy:Operator Pink Copy LEA ® ■ <br />