Laserfiche WebLink
Waste Tire Su- M & Inspection Re ort nspection Report Number <br /> State of California " <br /> �H CIWMB181 <br /> ante Management <br /> Survey Form - Page 1 1 t - 0 . 6 <br /> California Integrated Waste Management Board <br /> Part A- Starve BLUE OR BLACK INK PEN <br /> I Inspection Details <br /> TPID- 'ril� r _ r.- Eu_ <br /> Inspection Type (Fill one) <br /> Site Suffix - -� r Q Routine Q Re-inspection Q Referral Q Observation <br /> -Local If Referral,choose referral type(Fill one) <br /> Identifier: l.t, 1 ;�( rf _ir.:' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> --—_ _ f <br /> Physical Atldresss— <br /> � A-_ <br /> V0 LElft{ ,t � . , - <br /> Street p / F-1A <br /> Ins ection Date r <br /> J C .� ✓�.-.' I <br /> fk <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> E. <br /> O PM t O PM <br /> Pc <br /> Operational Status Business Role Storage Type <br /> r° <br /> (Fill one only) (FIII"all{ apply; (Fill all that apply) (Fill all that apply) <br /> N Active ,? � pti r<; (a)Generator 0 Outdoor <br /> r r a" zww�Y3"t�pu. <br /> 6 <br /> GPS ° 0 Closed p ° <br /> Latitude ldw � na J <br /> d)iy�� °ut/I= ���r, O Hauler D Indoor <br /> D 0 Inactive rr,r t ipx <br /> o <br /> End-Use <br /> Longitude 0 Planned 0 OTR Container <br /> g � Q <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair Q 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 <br /> 0 Notice Of Violation 0 Extension <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 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years _ <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I 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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments 7 J <br /> -- 1" (',> ...(� .11``��11--"( �• 6 i.J�'v ��i.t :;? r (.C- a f i•�.1 -.r.' �.1�`.',{ E-t I( A ! <br /> l �,'►C:C ''.G� -if'�i Gtt ' o 1�. ��C!'. Forf r,.- V L tf �1 <br /> �/� CJ� "�L;� r �r t"r '�`._�.. ! �C� ��.�l'v 4..{ � is f�l f i � ��'7 � �"C' C'{f✓� i j�l�'7 ��t_f It..t I r`( J';✓ <br /> In y '2 Tt r " , tip of hplf;rNeial777;z <br /> , ✓r"r `5hr %, <br /> " r '�:: �"#� - <br /> Business Rep's Signature Phone Number' Inspcto 's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK CorrectV Incorrect: X i; ;j A IV. -_` I_3 U; I I ._ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />