Laserfiche WebLink
OSIS7040035 <br />Waste Tire Survey & Inspection Report inspection Report Number ■ <br />rl� State of Caffomia <br />CIWMB 181 <br />(New 04104) Survey Form - Page 1 1 4- 1 0 7 9 2 4 3 <br />California lntegrated Waste Management Board <br />13-1la+ e - c..�.e.. RLUF OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID - <br />�� <br />I E X A M P I'L E1 -1M.23 <br />62081 <br />2 <br />[01 <br />Yellow Copy: Operator <br />Pink Copy. LEA <br />® <br />N <br />Inspection Type (Fill one) <br />Site Suffix: . <br />l! <br />J � 13-1- <br />7 <br />- <br />, <br />0 Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Local / <br />�jA,j <br />Identifier: T q in/ (_,OV _ <br />Q CHP Q CIWMB 'Q Complaint Q Educational Visit Q Other <br />Business or Facility Name <br />� <br />Inspected By Inspector <br />Physic A�dress <br />- l <br />� � I � � t-f/t�yQ,� j <br />302 A. aero kee Lo I <br />Inspection Date <br />Street <br />.527 o <br />�� ( <br />cit State ZIP Code <br />Business Rep Title <br />Time In Time Out <br />Q AM O AM <br />MOPM <br />�a>, DcJ r1 u <br />J <br />O PM <br />Operational Status <br />(Fill one only) <br />Tire Type <br />(Fill all that apply) <br />Business Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />i I <br />Tire Count (Whole/PTE) r � <br />3+� I <br />i r <br />Active <br />Q Closed <br />ie Passenger <br />Q Altered <br />! Generator <br />Q Hauler <br />Outdoor <br />Q Indoor <br />GPS Latitude <br />i <br />f I__ <br />O <br />__J_.__,_—.___.�— <br />I. <br />� <br />+_ <br />Q Inactive <br />Q Truck <br />Q End -Use <br />Q Container <br />Longitude - <br />I I __ <br />IO <br />Q Planned <br />Q OTR <br />Business Type (Fill ail that apply) . <br />0 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br />is 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 I <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility ENFORCEMENT STATUS <br />V A HAULING AND MANIFEST REQUIREMENTS <br />Q Notice Of Violation Q Extension <br />Q Q 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 Q 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements Date Ffl 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 or EX'S <br />Q Q 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 I 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 In Compliance - No Violations <br />Q Q 1 Other: <br />Comments Os -f %)J J's c+� / <br />ia�.c, , y%� � vlw <br />/.�Js_e� _L.c,fc„v_T/'rc_ritl�sr a s�_._J� ,.C_ <br />_.Gfa,►��'fr-a—a<s_(/ir.�.,�� A1o_f%io.�aa-�e�vs_D�-r GtG-�rTNS�/"c .— <br />Inspection Form Included: Q. <br />ZD9 <br />Comments Included: Q <br />• ,- 9c 8 9 <br />- - <br />Bu s Rep's Ignature Phone Number Inspector's Signature —Shone Number <br />INSTRUCTIONS ON BACK <br />C rrect <br />orrect: X (J� Rr <br />I E X A M P I'L E1 -1M.23 <br />62081 <br />0 <br />White Cpy.CIW <br />Yellow Copy: Operator <br />Pink Copy. LEA <br />® <br />N <br />