Laserfiche WebLink
■ Waste Tire SL ey & Inspection Repoi Inspection Report Number ■ <br /> State of California 11 - 1127715 <br /> CIWMB 181(New 04/04) <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L Q Routine ® Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: SC�VA '�(` i JIj � f (�/0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> sine <br /> Buss or Facility Name " 11� ! Inspected By Inspector <br /> M i`�v� 'Sp��- - 1 <br /> Physical ArW.sselrfaAA A16iz) Alem6k�_ <br /> (�?qO5 At. E( D&rac)b cS(-� <br /> S�k� � /,�� /� Inspection Date <br /> yl Time In Time Out ` <br /> Business Rep Title � �� ®AM �AM <br /> PM o� PM <br /> CcL�o►ri�( Sc�ncX -� ;� s4�ti�l�� - <br /> ------------ -- - -- ---- --- - Operational Status Tire Type Business Role Storage Type <br /> ' f <br /> Tire Count(Whole/PTE) 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ® Generator &Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <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 /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 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 or EXT) <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 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 Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: - (�KJ<�7./ C�/t�tf� e�/- -I -L--IJ- / (!_ Cha✓ ( (J/� <br /> — - - -- -- -Ph--- -- _ <br /> siness Rep's Signature Phone Number Ft1 ct ature - --- Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK j Correct:* Incorrect: i P 112 <br /> White Copy:CIWMB Yellow Copy:Operator Pin Copy: <br />