Laserfiche WebLink
+ 08227040106 <br /> Waste Tire Survey-& Inspection Report Inspection Report Number <br /> rtate of C1WM181(N- Survey Form - Pa e1 1 4 - 1 073:444 <br /> CNVMB 181(Naw na e) � n <br /> Califomla Integrated waste Management Board `J' <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile T Inspection Details <br /> _ a <br /> D I © / Inspection Type (Fill one) <br /> Site ffi <br /> Site Suffix: �✓ I I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: J OAQ__ ,r COtlN�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit'o Other <br /> Business or Facility Name Inspected By Inspector <br /> ( [3K <br /> _ ZJd L�A..�/ �d4•�0�n! I <br /> Physical Address t <br /> 5./0 /V VN,-a ,7 �T I <br /> Street <br /> —�n A �5� <br /> 15 <br /> Inspection Date Q O g <br /> City Com+ tate ZIP Code Time In Time Out <br /> Business Rep TitleO AM Q AM <br /> m'm O PM [j] m Q PM <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(WholelPTE) {I <br /> ^� '0 Active o Passenger 0 Generator. 0 Outdoor <br /> ll I 0 0 Closed o Altered <br /> GPS Latitude H L—�� 0 Hauler o Indoor <br /> I� _ O �Inactive 0 Truck <br /> Longitude I _1__ _ 0 Planned 0 OTR o End-Use o Container <br /> Business Type (Fill all that apply) .1� <br /> o New Tire Dealer 0 Auto Repair o Trucking Fleet 0 Government o Retreader 0 Dismantler 0 Tire Derived Fuel <br /> o Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> o Service Station 0 Hauler 0 Agriculture o Shredder 0 Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility RIENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Notice Of iolation <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires V 0 Extension <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 <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 (Requi ed for NOV or FXV <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 o 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 In Compliance No YOf–ions <br /> 0 0 Other: § / �7l / 1 <br /> Comments � „�SPLcT�'M_¢j9 l � 4 <br /> �CT�A__._�1e :�/�i•t� ►'+►t /79.at 7"T�� da �o_T�e..,O a�i'T. •r' �y�.,,a....,�e <br /> r/Sse�(/ lar a,tl ' 4ecv Q7r��ltc ✓ .'��✓sw-?-COW <br /> 'aa <br /> G�i•.s Nb m-0 ' <br /> /fib I/r'al«�r's..s e2 Lie„ <br /> inspection Form Included:0 209 <br /> Comments Included: Inspector's Signature ps gnaLe Pongmer — <br /> Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor ect: Incorrect: t= X A M P 'L E Z 2 3 <br /> . White Cop CIWM Yellow Copy Operator. Pink Copy LEA ® ■ <br /> _ I <br />