Laserfiche WebLink
.r,1: r A.i <br /> 4 <br /> �1 <br /> t,.. <br /> = c ; Waste Tire Survey & Inspection Report Inspection Report Number_ <br /> 9tBH2 State of California — <br /> �� CIWMB181(New 04104). Survey Form - Page 1 Il 1088100 <br /> California Integrated Waste Management Board Y J --- -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i i I Inspection Type (Fill one) <br /> Site Suffix: ?I � OI � V� 317 <br /> - 0 Routine 0Re-inspection 0 Referral 0 Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier: _O— _ _ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> GOO�__� t ►�. � 1�191 <br /> Physical Address - Ll <br /> I I:][ ! <br /> J 3 9S S a <br /> Street Inspection Date I of I ! 3 I 16 9 <br /> City State �;��:� • Time In _ _ Time Out <br /> Busine <br /> ss Rep Title ', ! I lO i leAM f-- {V : D 1 i , ��!O AM <br /> GZ� } � DVVVIILI ­ - -- --- OPM --� --1— -- - QPM <br /> -- - - - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) Q 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active 10 Passenger 0 Generator a Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude ® Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR ® End-Use ® Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other L I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _--------- <br /> y <br /> V , A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 1 Other: § _- _ _ _ <br /> Comments /_ <br /> JVJV0je7 'e_a4M ff:e� lore-swVt . all mw_�"�f_-ar_yyuz <br /> 4-�Y-,e L" R\4 <br /> Vy- <br /> Inspection Form Included: ® (� 19 6(V <br /> Comments Included: ® — ! ✓ I — — <br /> Business Rep's Signature Phone Number Inspecto ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co rec o Incorrect: X ( X A P . E 1 2 3 <br /> White Cop .jy <br /> Yellow Copy Operator Pink Copy.LEA <br />