Laserfiche WebLink
i. <br /> Waste Tire Su Y & intpection Rep o Inspection Report Number <br /> State of California <br /> CWMB <br /> 181 04/04) <br /> I 1 o 2 <br /> California Integrated Was eeManagement Board Survey Form - Page <br /> age 1 <br /> 80 <br /> Part A- Survey - - - - - - - BLUE OR BLACK INK PEN <br /> Business Profile ,Inspection Details <br /> f TPID- O - �1. I Inspection Type (Fill one) <br /> Site Suffix: � 9 - ® Routine O Re-inspection O Referral O Observation <br /> - If Referral,choose referral type(Fill one) <br /> Local <br /> Identifier: Y 'SG n TOG?u A n C o(.A n-tj <br /> O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Tire ..��7.SL«J <br /> Physical Address <br /> street <br /> L O C1` C Inspection Date 1--o—ii / L' <br /> _�_ _9 Time In Time Out <br /> City Statc> Z'ff�Code <br /> Business.Rep Title II �OAM J'—] 0 AM <br /> r —1�.� O PM Q PM <br /> Akan Ck ex. <br /> Operational Status Tire <br /> Type Business Role orageType <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that,a Count(Whole/PTE) PP <br /> I <br /> Yt <br /> . <br /> ® O Q Generator O Outdoor <br /> OClosed O Passenger <br /> PSLatitudeG <br /> O Hauler O Indoor <br /> O Inactive O Truck <br /> O <br /> Longitude - O Planned O OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer (j) Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder O 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 /> O Notice Of Violation 0 Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date O / m / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators F In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> /� -- ou�1C' �Y-_ Coi ICA-()rrYc�1 -4 r,, � .t'1e -�._`__, ol�osrl rl v,3:� r ;() er <br /> t=i�_ <br /> on-inc Yorrl <br /> u�„ 4 - __— __— -. �':_ i h9 a7 ray. pig 7 ,h if1 ✓"l; f iu, <br /> Inspection Form included 0; <br /> � y <br /> " - �� �r - t j <br /> Comments Included #I 7th I <br /> Business Rep's Signature Iffione Number I pector s Signature" Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X A�, ;X A M. P.. LE: ! 1 2 �3 62081 <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />