Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection 1114AWMW <br /> •••[t[ Btala of Ggfornla I <br /> CWM5181 IN—04104) Survey Form -.Page 1 1 .2.- 1 01 0 8 0 9 <br /> GlirOmla Imagralad Waata Management au.M <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Buslness Profile Inspection Details <br /> TPID- 2 / Inspection Type (Fill one) <br /> Site Suffix: / -3 $ 9 -5 - Q ! IS Routine Q Re-inspection Q Referral Q Observation <br /> Local H Referral,choose referral type(Fill one) <br /> Identifier: Lx"'_V4OCHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physiwi Address F/ R ) I iS1So iy��� <br /> Street /Los�Gr Q 7� <br /> _ 9SoZf/ Inspection Date <br /> � <br /> City late Z!P o e Time In Time Out <br /> Business Rep Title � �w— m'm O PM m'm O 0 AM 0 AM <br /> 6pi's 1 r PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 0, (Fill one only) (Fill all that apply) (Fill ail that apply) (Fill all that apply) <br /> Tire Count holefPTE I Il 3(I� <br /> Active Passenger 0 Generator Q Outdoor <br /> 1 �O Q Closed Q Altered <br /> GPS Latitude W IL_JI_IL` 0 Hauler Q Indoor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned Q OTR Q End <br /> ®Container <br /> Business Type (Fill all that apply) 111 <br /> i 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A I HAULING AND MANIFEST REQUIREMENTS 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 /> 1010 1 Other: § ./ <br /> Commends ' �[�ova_ le J GrL1Ky Clue✓ 8C6c( 6 .d '-14S'/:e L _ /t/ec'e /a yS'9 <br /> ,fP 33/yo83 <br /> Inspection Form Included:Q <br /> Comments Included:® - <br /> _ 116siness Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:40 incorrect:tRo ld EXAMPLE ' Z 2 3 62081 <br /> ■ While Copy:O W N18 Yellow Copy:Operator Pink Copy.LEA ® ■ <br />