Laserfiche WebLink
Waste Tire S4b-ey & Inspection Repor Inspection Report Number <br /> State of CaliforniaC,WMB 181 <br /> ew 04104) <br /> California Integrated I Waste Management Board Survey Form - Page 1 1 1127467 <br /> 'art A- Survey_-- - --_- _ _ BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection o Inspection Type (Fill one) <br /> Site Suffix: �J ® Routine Q Re-inspection Q Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: 1 ' r MLl <br /> San f� W Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> cckn oA(JI, (N <br /> Physic Address <br /> aLkoo �,ovl+ S� Ave- <br /> / Inspection Date (91 <br /> L 4 Time In Time Out <br /> Business Rep Title ` ® AM *AM <br /> , ` () ' 1 0 O PM 3 Q PM <br /> -C--r-'r)C' U_�4Cs - u^w-�1 r - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> o *Active Q Passenger 0 Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> o Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 <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 <br /> 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 EX7) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> - <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: § 1 n <br /> Comments aa <br /> t <br /> 5 m c.Lo� Ce, <br /> (inspection Form Included: <br /> Comments Included: Q -�/ ''� <br /> Business Rep s Si a ure Phone tuber &In�pjrsture one Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct. Incorrect: X S ; 2 1 3 1 <br /> White Copy:CIWMB Yellow Copy: error ink Co <br />