Laserfiche WebLink
InspectionFfe ort Number. <br /> Waste Tire Survey 8� Inspection Report p <br /> Blab Cslgomia. Survey Form - Page 1 1 1 - 1 0 7 9 4 9 6 <br /> CIWMB 191(Naw 01101) Y <br /> CdMomla Integrated 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: [/ 3 4 3 L -5 - ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: -�pc�r�,o�, 10CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility <br /> /GName ^/ Inspected By Inspector <br /> (Physical Addres <br /> Street Inspection Date <br /> 9S-go YJ <br /> City State Zip Code Time In Time Out <br /> Business Rep Title OA O AM <br /> A,. PM LLJ <br /> M ®PM <br /> -� P --- ��V 1 cit A -ior;I Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE): (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> 0 ®Active ®Passenger ®Generator Q Outdoor <br /> - I 10 Q Closed Q Altered <br /> GPS LatitudeQ Hauler ®Indoor <br /> - -- -i- -`----J Q Inactive Q Truck <br /> Longitude - i I I ,I I I I Q planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body ®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 A I HAULING AND MANIFEST REQUIREMENTS <br /> 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. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 E)T) <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/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 /> Q 10 1 Other: § <br /> Comments <br /> - - �"x.a.�-.-,.r,•, C'ti..--�r�rS �lete.��Li�Lcsc-S—w-�-2L_tL�frK <br /> —1�ae,S1c. �+�,�.—c��s�-�'DT�v,•,'�,. lr�rn�rc�.<.�s�� �,.�-1.�2�as <br /> Inspection Form Included: I <br /> Comments Included:Q Ltboo <br /> Busines a Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BA orrect: Incorrect:X(� q 10XjAjjMjP1L1E11 '2 131 <br /> 62081 <br /> ■ White C MB Yellow Copy.Operator Pink Copy.LFA ® ■ <br />