Laserfiche WebLink
090220SO045 ■ <br /> ere- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of I1 — 1088344 <br /> CIWNBtet thew 04!01) Survey Form Page 1 <br /> Caleomla Integnrted Waste Management Board <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q Inspection Type (Fill one) <br /> Site Suffix: 00 1�3 E�Irs I ®Routine 0 Re-inspection 0 Referral Q Observation <br /> Local Ca�u,b If Referral,choose referral type(Fill one) <br /> Identifier: rjQ(� ��riA n ` Q CHP 0 CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name – <br /> Inspected By Inspector <br /> Physical AddressCr I [(K[I <br /> I <br /> V <br /> L7dt).i ='Z_� <br /> _ -- <br /> S'reet <br /> I e Inspection Date 1 a I a, LP 8 <br /> City _l_��_I_I — State [IP Coe Time In Time Out <br /> Business Rep MM �I Title ��,O AM ' O 40 AM <br /> O <br /> _ ._I111�,Q[ �_ _iPM LOPM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply)- :(Fill all that apply) <br /> Tire Count(Whole/PTE) r a 0 <br /> 0 Active I*Passenger •Generator .0 Outdoor <br /> O O Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> Q inactive le Truck - <br /> Longitude – 0 Planned 0 OTR O End-Use (a Container <br /> Business Type (Fill all that apply) <br /> •New Tire Dealer O Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Q Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> 0 Service Station O Hauler O Agriculture 0 Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 O PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs Within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred I CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> 10 1 0 1 Other: §, _ rr ( _ <br /> Comments �ell�; ���CO ll�ibw�ny�c�ill'A .— <br /> Rctov�s_ }for ' ��s- s--a�ofoc con4 ai res o�se� Cl�voMir aa-mil <br /> P� > <br /> L &(kA "0rrrS_ <br /> Inspection Form Included: �3Y 39`r <br /> Comments Included:Q r �Wto <br /> I usin s Rep's Signature Phone Number Inspector's ignature Phone Number <br /> INSTRUCTIONS ACK I Correct:* Incorrect:�(� 62081 <br /> White <br /> EXA P ,LE 1 .2 .3 <br /> . _ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />