Laserfiche WebLink
08.81804818.3 <br /> m <br /> Waste Tire Survey-& Inspection-Report Inspection Report Number <br /> rr Stats of Callrornla <br /> CIWMB tet IN—04104)-- Survey Form - Page-1 .. 1 5 - 10 7 3 3 7 9 <br /> Calft Intagnted Waste Mamgemem Board <br /> Part A-Suroe . BLUE OR BLACK INK.PEN <br /> Business Profile Inspection Details <br /> TPIDI I ) - ( inspection Type (Fill one) <br /> Site Suffix:. 0 0 Routine Q Re-inspection Q.Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other . <br /> Business or Facility Name U U Inspected By Inspector <br /> I—� _oPhysical <br /> _v�#o' <br /> I Address <br /> 909 E. Pi nn. St. I <br /> Street Inspection Date !. <br /> City Lo � � 9ware 5�ZQ O de I Time In Time Out <br /> It,Business Rep !J(� Title /,t'/A O AM 0 AM <br /> /v J m <br /> ELI <br /> O PM m m O PM <br /> ------- - -- _ _ _ <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)+ l r i I f (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> V_� ®Active ®Passenger ®Generator ®Outdoor. <br /> Q Closed Q Altered <br /> GPS Latitude m, Q Hauler Q Indoor . <br /> 0 Q Inactive Q Truck <br /> Longitude -.=-L Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire.Dealer (jo 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 Q Hauler Q Agriculture Q Shredder Q Other 1 I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility E. N�ORC-EMENT STATUS <br /> V A HAULING AND MANIFEST R-E-01111REMEN-ITLS1 Notice Of Violation Q Extension <br /> Q . Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> o Q PRC§42956-RegistrationiDecal in Vehicle <br /> Q o 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB - <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or <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 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> o Q 14 CCR§18462-Manifest System'Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Q 10 1 Other: § �/ (, <br /> Comments RUl�ihe� -�"} I F'N� TU O 1� l.l�(k _aQ� <br /> ,.o ` '` i►�c4c-c�tL�,—`mss 6�'� <br /> 1/10t��-fi)r^e 0 anot_h�t <br /> DInspection 4L F Included:Q <br /> Comments Included:Q -- -A <br /> —nessnet I Phon umb Inspecto Signature Phone Number. <br /> 62081 <br /> INSTRUCTIONS.ON BACK C-orreet:� Incorrect: 0 X A P. X 1 2 3 <br /> ■ - White Copy CIWMB Vellow Copy.Operator Pink Copy.LFA ® .. <br />