Laserfiche WebLink
ICO_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> StateN <br /> CMe <br /> 181 mla Survey Form - Page 1 1 1 - 10 7 3 3 3 4 <br /> M/ 1g1(New 04!04) <br /> CalHomia Integrated Waste Management Board <br /> Part A-Surve _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- O / Inspection Type (Fill one) <br /> 1 <br /> Site Suffix: . O 1 <br /> , - 0 Routine 0 Re-Inspection 0 Referral 0 Observation ' { <br /> Local T If Referral,choose referral type(Fill one) <br /> Identifier: �a(/t JpQ n-C )/� 0 CHP CIWMB <br /> �3LLfL.�cf Q Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name (/J� <br /> Inspected By inspector <br /> Physical Address <br /> I <br /> 19 5 00 - <br /> Street <br /> �//./tLIJ- q5�L/CCode <br /> Inspection Date <br /> I I CJ <br /> City State Zip o e Time In Time Out <br /> Business RepTitle O AM <br /> 0 AM <br /> I & KI. i`S _J L,./ —/V ' m m 0 PM m m O PM <br /> Operational Status Tire Type Business Role ; Storage Type <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) '(Fill all that apply) (Fill all that apply)s" I t <br /> 1.00 Active 0 Passenger D Generator 0 Outdoor <br /> I` I I O 0 Closed 0 Altered GPS Latitude IBJ.��� 0 Hauler 0 Indoor <br /> T <br /> O ®Inactive 0 Truck <br /> ILongitude - � � I 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer '0 Collection 0 Crumb Rubber r <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other �l lk 'Q✓ <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 0 Extension <br /> 0 0 PRC§429511-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data m / m / m <br /> 0 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years -'- <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred 1 CIWMB Enforcement <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (!a In Compliance No Violations <br /> 0 1 0 Other: § <br /> Comments - <br /> 1al_< )r 6, Av-s';08) j . uq CTL- yiec�rcoC _ <br /> OrkL tt e tits s. DLSC.c� Sid 1�e Pro ram , 1-6 w ✓alit <br /> v <br /> Inspection Form Include :0J^ p <br /> Comments Included: � '�-S'�!L/� <br /> ABu.I. ss s Signature Phone Number In_e or'sAgnre Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X(� E X A Ill P L E 1 2 3 s2os1 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy LEA ® ■ <br />