Laserfiche WebLink
�l$5^ 904103 <br /> cra. <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ar CVNMr181Survey Form - Page 1 I 7 - 1 0 7_2_8 1_� <br /> CONMB 181(Na.( 04!04( <br /> califomia Inlagratad Waste Management Board <br /> Part A-Surve . BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �'I I s 2 I ©� I - O 1 Q Routine Q Re-inspection Q Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: „) J DAA 4 tW (tvN G].t_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name /I <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> STei c_kA y) d4 '?520—' <br /> ?520 Inspection Date <br /> City State ZP Code Time In Time Out UUU <br /> Business Re/Ip / TitlAe, Q AMO AM <br /> t_a;Ka..l.►_��fFilld i�_//`��•----J m•m0PM �'Ej] <br /> 0P <br /> -- I Operational Status Tire Type . 'Business Role Storage Type <br /> (Fill one only) (Fill all that appy) .(Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ( ' 0 Active Passenger 0 Generator Q Outdoor <br /> GPS Latitude mi O Q Closed Q Altered <br /> Q Hauler Q Indoor I I <br /> F. •L 0 Inactive 0 Truck <br /> Longitude - 1 _ 111 1. Q Planned 0 OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> _ <br /> 0 New Tire Dealer Q Auto Repair 'Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 0 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 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility NENE0.CEMENT STgTUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS 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. G^am ance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <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 t C-iWMB 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:§/ p <br /> Comments 0125 Z-✓.i4IIae/ <br /> be vsi�vrc A)044e 9eco04.t��J .lac. As���✓�isf�,�e%0 <br /> ae Grak /e,�. Have �«d�l�—rte -� �:.��5 ;o, Lw /V_d"J� <br /> �LVc�V�o_�,�TO_Y_IS ct2._Co_h_ce�-tis �oT�o� <br /> Zo <br /> Inspection Fore Included:Q <br /> Comments Included:Q <br /> Business Rep' ignature• Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK rrec Incorrect: E X A M P E 1 2 3 <br /> ■ White Co :CIWM Yellow Copy:Operator Pink Copy.LEA ® ■ <br />