Laserfiche WebLink
tta <br /> Waste Tire Su . :y & Inspection Report inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1141029 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> I TPID- Inspection Type (Fill one) <br /> Site Suffix: C) 3 S - © ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local _ If Referral,choose referral type(Fill one) <br /> Identifier: n C' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> i <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3 - f 0 A <br /> ftw�Ca,1nC.�Ct (30r��-r«" <br /> 42 <br /> Inspection Date (� 02 / t <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> S 0 PM O 3 ®PM <br /> j I Sa.C���� �W►�,a.Y - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply)j (Fill all that apply) (Fill all that apply) <br /> f f 3 0 Active 0 Passenger 0 Generator ® Outdoor <br /> I � <br /> Latitude 0 Closed 0 Altered <br /> GPS • O 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned — 1 0 OTR 0 End-Use Is Container- <br /> l 1 <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 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <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 /> — --- - — <br /> 0 0 PRC§42951 -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 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 /> 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/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 Violations <br /> 0 1 0 1 Other: § <br /> Comments )/� <br /> - - °SO_n_+-(itA )gCPCc,,H Cv--- 4-t, c.( AZA_ <br /> fb(lc wC( 1nUkI,( - <br /> Inspection Form Included: 0W'lf J-o� <br /> Comments Included: 3. <br /> --X - - �Z�`1 6�� � <br /> Busm ss Rep's S cn ure Phone Number nspector's Si ature Phone Number <br /> - -- <br /> _ _..._F....... 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: . �/ X A � 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />