Laserfiche WebLink
r \I ` <br /> Waste Tire SL . ,v�y & Inspection Fkepol inspectionReport Number ■ <br /> taint . state ofCalifornia <br /> Wal CIWMB1 (NewO4/g4) Sine`, Form Page �+ b 3 <br /> California Integrated Waste Management Board J ge <br /> Part A - Survey BLUE OR BLACK INK PEN <br /> — — - - - — <br /> Business Profile Inspection Details <br /> i TPID - O � Inspection Type (Fill one) <br /> Site Suffix: �} O j.1j Routine Re-inspection Referral Observation 'I <br /> Local L If Referral, choose referral type (Fill one) <br /> Identifier: SA'f1 SOgquip GOurT1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - Inspected By Inspector <br /> 1 Si-c n s on _-.-- L o tis �_.._..._..EL I <br /> Physical Address <br /> 3 � l <br /> IJ43-00 - Har \ an R�--.._._._.-......._.__.- _ _i - -- — <br /> Street f l f <br /> Inspection Date -O�� / 1 F- / LO 8 I <br /> CdV State ZIP Codt< Time In Time <br /> e .� .. . I Out <br /> Business Rep _ <br /> Title AM O AM O <br /> 0 PM : � O PM <br /> / (peration Status Tire IyhBusiness Role Storage Type <br /> (Tire Count (Whole/PTE) Fill one only) all that ( all that a apply) Fill <br /> all that apply) ' <br /> ® Active Q Passenger Generator Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q /�inactive (D Truck N <br /> Planned <br /> Longitude — Q nned Q OTR Q End-Use Q Conte <br /> Business Type (Fill all that apply) ine <br /> LON ireDealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> e Station Q Hauler Q Agriculture Q Shredder ® Other I v:WJf t b Uti O n Len}-C <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 1 <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 m1:11 <br /> / / m <br /> Q Q 14 CCR § 1845§. 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 EXT) <br /> Q Q 14 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 <br /> r10 s1�r�� �y 1�1s$s— 3rcirinon re oY�r tic <br /> jYCAT-Ior --t )r �-) Fr SeCNhcP rerAasqa f bn vrern \ sem__,— �ve <br /> beQn c- C,XY,/ , a avu \ l QVC -1 �0f \/ Ic r ' 100Y) tel( +es <br /> l <br /> I <br /> F <br /> i <br /> :Ins ecton Form Included: Com ) <br /> " QI <br /> �1 _ <br /> Comments Included : Business Rep's Signature . Phone Number In - pe tots Signature / Phone Nr�u umbeer <br /> 62081 <br /> ■ INSTRUCTIONS ON BACK Correct: 40 Incorrect. X �tpI [ I A MII 1 <br /> White Copy: CIWMB Yellow Copy Operator Pink Copy: LEA <br />