Laserfiche WebLink
:. <br /> y & Inspection Report Inspection Report Number <br /> Waste Tire Suf <br /> "ailiIN State of California <br /> CIWMB 181(New Survey Form - Page 1 I 1 - 1140666 <br /> California Integrated Wastt Management <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN__ <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Ll / 9 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: DAn Tan[J,,,^ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> &6 Ccan <br /> Physical Address <br /> Inspection Date / / 7 / / U <br /> CA `rS�v� <br /> Time In Time Out <br /> Business Rep Title / a ® AM 0 AM <br /> ` O PM 7 0 PM <br /> 311 5 cuts" - Ste-„;ce. W p - <br /> - O erational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �j j ® Active 0 Passenger 0 Generator s Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude – 0 Planned ® OTR 0 End-Use 1 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 /> l0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service <br /> Statin ler P <br /> 0 ervic. 0 Hauler U Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility r ENFORCEMENT STATUS <br /> V A HAULINGAND MANIFEST REQUIREMENTS <br /> .. _.. 0 Notice Of Violation 0 Extension <br /> ___.... _ _ <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i <br /> 0 i 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 Date 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 /> 0i0 14 CCR 18459.3-Retention of Comprehensive Trip Logs for 3 years II <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 i 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance No Violations <br /> 0 0 (Other: § <br /> Comments (�_ <br /> i-RA, IY�S�E Lw— _©� ° 010 OUAJ `�t^ TTS��(uuu V15 _ <br /> Uv(�S V1U�� <br /> Inspection Form Included: QI <br /> y /-�O� / f.Zog y&$r0—/ <br /> y <br /> 4 <br /> Comments Included: ®i Business Rep's ignature Phone Number nspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X '.4k V I j E Xi 1112131 <br /> White Copy:CIWMB Yellow Copy Operator Pink py: <br />