Laserfiche WebLink
. 0731904OL67 <br /> Waste Tire Su&y & Inspection Report•Inspection Report Number ■ <br /> state of California <br /> CIWMs tet(N-04104) Survey Form - Page 1'.. .� 1 3 - 1 0 7 3 4 6 8 <br /> California Integrated Waste.Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: i� . S 0 .0 Routine Q Re-inspection Q Referral Q Observation <br /> Loral If Referral,choose referral type(Fill one) <br /> Identifier:. L -recta,,v-- Q CHP Q <br /> CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected BYinspector <br /> I (ellTI'wV�t I <br /> Physical Ad r�ess ;3 Mo <br /> Street <br /> I60y 5—� <br /> m 3 1 <br /> Inspection Date <br /> I Sfv�rt GI� l I <br /> City Sta(e ZIP ode Time In Time Out <br /> Business Rep Title0 AM 0 AM <br /> —S � olt+/Y}e ` I'�ctytp-�Cl� m m 0 PM m'm WPM <br /> Operational Status Tire Type Business Role . Storage Type <br /> Tire Count(Whole/PTE).! i T p,T , (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I a Active IS Passenger ®Generator Q Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude �� Q Hauler Q Indoor <br /> O O inactive Q Truck <br /> Longitude _ Q Planned .Q OTR Q End-Use ®Container. <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ®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 Q Other I_�ae,Frs I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ------------------- <br /> V A HAULING AND MANIFEST REQUn <br /> IREMENTS <br /> Q Notice Of Violation Q Extesion <br /> Q Q <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements. Date m / m / Ell <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 EXT) <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/CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators S In Compliance - No Violations <br /> 101 Q 1 Other: § <br /> Comments <br /> _�1V-1 '�c.XYom^-`rr-��t--1V(r1.�QR�' TLL �-��31T'�y 1 r,ae1��—I•_a�--7-'a�_4 c1L� <br /> ,�t,N�p� ►• i rt„ _I_ rN rah—�1T.s4ct3':.— CfJrrl Wt.ey�6�C,rtD+#+ <br /> r Wk.f1e- .H'Irr_ e1.Ypo(p.Q 7t C.?L. <br /> Inspection Form Included:Q Y - r^M- `/�� <br /> Comments Included:Q " - J by�Of:°L'3 <br /> Business Rep's Signature Phone Number nspectors Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK 31EMAIMIPILIE1 1112131' <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />