Laserfiche WebLink
� 016�Q�7012 <br /> Waste Tire Survey & Inspection.Report Inspection Report Number <br /> State of California I 1 - 112 7 6 2 2 0 <br /> CIWMB181(New 04104) Survey Form - Page 1- - <br /> California Integrated 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: "� ( pL t0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier:IdentL7��q�f'�l n _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> le <br /> Physical Address � � <br /> .65-1 .t PAt C7, I <br /> Street /y <br /> JAauc&�L C�- 95� Inspection Date <br /> City State ZIP Code <br /> 1 I Time In Time Out Bu—siineevsssJvRl.e�p itTitle"-'-�-- � --t [E/ / :F�� ® AM J ®AM <br /> O PM L <br /> �� <br /> PM <br /> -- --- - — 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) f f <br /> Active Q Passenger ® Generator Q Outdoor <br /> 4 i I 0 Closed Q Altered <br /> GPS LatitudeTEI <br /> J Q O Hauler Indoor <br /> Q Inactive ® Truck <br /> Lon itude i��� I Q End-Use . Q Container <br /> 9 - .I I I I - Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> 1 Q New Tire Dealer Q Auto Repair ® 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® OtherLA( <br /> ..Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use.Facility '-ENFORCEMENTaSTAT�US <br /> V .A NA -;REGUIREMENTS, <br /> . Notice`Of ViolationMINGAND°MANIFESTQ�Extension„ <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> �s <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. corri'plia'n`ee`Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date,, /`I I I IMI I a <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMBI I I I I <br /> Regmred for NO V or <br /> Q O <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 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referlred I CIWMB Enforcement'# <br /> Q Q <br /> 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ew. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � q <br /> ;Ina Compliance.-eNa Violation <br /> i Other: § '. <br /> Comment <br /> � l i s ene��ff LLo i-fes .f D� ` n__ den ops, 1�tJ�l <br /> t6s Q�(R�C� des - t,e �fl ��7 <br /> �' __ _ '� ✓� V!9 l `n ' ►26 s 011 . <br /> Inspection FormInclud d: Q <br /> Comments Included: Q -- - -- � �� <br /> Business Rep's_Signatur Phone Number Inspector's Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rec Incorrect:.,( t jn EjX AJM P E 1112131 <br /> White Copy: IW B Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> I <br />