Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> rid Stale of California <br /> CIwMe 187 ie ) <br /> Californiaurvey Form - Page 1 I1 - 1088438 <br /> ifornia Integrated WasttManagement <br /> Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- In41 spection <br /> - Inspection Type (Fill one) <br /> Site Suffix: i Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: y� � (��� �(i�n}t Q CNP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (� ( Inspected By Inspector <br /> LL..,,�-- Se rA_A ?? _ <br /> Physica( ddress J l AOT,,,,/, J`f1'GiYyI�L'}" <br /> "N - K <br /> Inspection Date Lr 0 <br /> A-ua.vxfv Cc, g5o?d3 -( <br /> I l <br /> Time In Time Out <br /> Business Rep Title Q AM O AM <br /> Uw NE/Z ' O o PM O 0 PM <br /> RCS\ D#14t*I'- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t `5 0 Active 9 Passenger 0 Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer !Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 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[_7 <br /> / 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 014 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 Q Other: § <br /> Comments f1GvtMe, wU�ke_ +"G cI A <br /> -�1'1e Evlla-.T�c, WctS �i:-kG . <br /> Lct <br /> Inspection Form Included:Q a� 6L <br /> Comments Included:Q __ -____a�___3—_--- 16�3- <br /> Busi ss Rep's lure Phone Number In to s ignature Phone Number <br /> t /..( 62081 <br /> ■ INSTRUCTIONS ON BACKCo <br /> Cay ciCtouoPy Opeov XIoA /V� P}�. ® ■ <br /> A <br />