Laserfiche WebLink
0832SOSGGG5 <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> °Ir �ul <br /> CIWMBf181(Nmia Survey Form Page 1 SI I 1088397 <br /> CIWMB 11 (Now04104) <br /> c' <br /> alifomla Intogralotl Waste ManagumaM board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- -_I � 1 <br /> �f--J_T -I Inspection Type (Fill one) <br /> Site Suffix: ®Routine QRe-inspection <br /> Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: L_ _V 1 RF,, JI Q CHP 0 CIWMB Q Complaint tQ Educational Visit Q Other <br /> Business or Facility Name Inspected 8 <br /> P Y Inspector <br /> Physical Address <br /> Street <br /> G495"33 Inspection Date <br /> /"`- -- a Time In v Time Out <br /> Business Rep Title -�j� O AM - - O AM <br /> S Pas Coo rdu - - - - O PM -- -- - O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire C nt(Whole/PTE) (Fill one only) (Fili.all-that apply) (Fill all that apply) (Fill all that apply) <br /> f ' ®Active Q Passenger ®Generator Q Outdoor <br /> U Q Closed O Altered <br /> GPS Latitude ®Hauler Q Indoor <br /> _ D 0 Inactive f0 Truck <br /> Longitude - Q Planned Q OTR O End-Use ®Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®Trucking Fleet Q Government O 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 ®Hauler Q Agriculture Q Shredder (0 Other L�OntrK mil e� _I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS <br /> O Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m/m <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 orEX7) <br /> O O 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 Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> Other. <br /> Comments —' --- --- `-�x;C— r `'�—✓0��6Gt�-L e �LLCC.�� <br /> /O_�v),t�k 'tY_ ��. Thi-e¢. ` 'f�cfc.s t�►^e re�tse,"eo�ta <br /> ha Ls eye -CA ►ner- C r✓'er,+14 , Who 's ci Font. <br /> -6-tk -S am— -T-L<A Gzs C rVI OYN <br /> Inspection Form Included:Q _� <br /> Comments Included:(a - — - �—03 <br /> Business R 's Signature Phone Number Inspector's S1 °ature Phone Number <br /> INSTRUCTIONS ON BACK Co rect. correct: (� 62081 <br /> ■ E x a �q LEA i z s ■ <br /> White CopACV Yellow Copy Operator Pink Copy.LEA <br />