Laserfiche WebLink
09203050038 <br /> E_cef Inspection Report Number <br /> „_ Waste Tire Su�ey & Inspection Repo <br /> ki. <br /> ; State B Cal l(New <br /> I _ Il - 1086913 <br /> CIWMB New 04/04 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- Inspection Type (Fill one) <br /> Site Suffix: 0 AA `./ 1 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5[�� J•�►�.+� O CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> LW%'k_ Ulm 1S—C.0 <br /> Physical Address m O I <br /> Street <br /> �,..V\l�`► C A Inspection Date Vll 11 /U) 11 <br /> te - "A -95 3 � <br /> City State ZIP Code Time In Time Out <br /> Business Rep ` Title ��O AM ��i . Q AM <br /> I L I O 1OPM 1 ' �� PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ` . 14 Active ® Passenger I&Generator ®Outdoor <br /> O O Closed O Altered <br /> GPS Latitude i O Hauler O Indoor <br /> o O Inactive S Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet O Government Q Retreader O Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> O Service Station Q Hauler Agriculture Q Shredder O Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility RENF.G.RZEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q 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 / <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 FX7) <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 Q Referred/C-IWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In C-ompliance - No Violations <br /> O 1 0 1 Other: § <br /> Comments <br /> Inspection Form Included: Q- <br /> Comments Included: 20� � 49z-St{ <br /> is _ <br /> Business Rep's Sign ture Phone Number Inspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK Co ect: Incorrect: 62081 <br /> � � A 11A P �L E�� 1 '2 3 <br /> White Co .CIW Yellow Copy.Operator Pink Copy.LEA <br />