Laserfiche WebLink
Waste Tire SL'ey & Inspection Repor'l Inspection Report Number ■ <br /> � ® Stateof California I 1 - 1088297 <br /> CIWMB 181( e ) Survey Form - Page 1 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey -- BLUE OR BLACK INK PEN <br /> - — <br /> Busmess Profile Inspection Details <br /> �u _...._ <br /> TPID- ( + V �y V Inspection Type (Fill one) <br /> Site Suffix: ' 'O Routine Q Re-inspection Q Referral Q Observation <br /> Local Gn Sam LI'V) Couh�- <br /> If Referral,choose referral type(Fill one) <br /> S � <br /> Identifier: � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> -C)"F-11-1, <br /> J <br /> Physical Address j — I ( St l a r1 LU GQ_[9 <br /> 5 J <br /> street Inspection Date <br /> � � EO'1_�_Lq <br /> irate ZIP Code Time In TirVe Out <br /> 5] <br /> Business Rep Title !! '' 0 AM 0 AM <br /> (2y PM <br /> ClQ_r — <br /> C rl Ci Operational Status Tire Type Business Role Storage Type <br /> l,l� �CUhk� hOIeQT Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � I ® Active Q Passenger (3 Generator Q Outdoor <br /> D <br /> GPS Latitude <br /> EQ Hauler Q Indoor Q Closed Q Altered <br /> O Q Inactive Q Truck <br /> Longitude 11 Q End Use Q Container ner <br /> . �� <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer @ Auto Repair Q Trucking Fleet Q 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 <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 <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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 /> 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 f CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q li * 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> Rou�'1u�'e � -i�.e. -�-c� o W►n- WA <br /> n o-�ed A- t41 te used__ ►res c►k� er _ _�n �t�e • FUc���_ <br /> rox. <br /> ui:es PQ c;s %Tep} Cosa . _ serV C e_- e IM removal . <br /> C�Tt_ rte, �nt�te s hnve_ been ere- c�v����_���e- �C,r -1IAIY, <br /> s, <br /> Inspection Form Included <br /> Comments Included:Q — - - - - — - — - <br /> Business Rep's Signature Phone Number I p ctor s Signature Phone Number <br /> - / - 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X i� s/ E Xi A M P i l� E 1 12 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />