Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Survey & Inspection Repo. ti. <br /> State of California I 1 - 1143697 <br /> C1WMB181(New 04/04) Survey Form - Page 1 <br /> « California Integrated Waste Management Board _ BLUE_ O_RB__LA_C_K_ IN_K__PEN <br /> A- Surve�_- <br /> -- -- <br /> ness Profile Inspection Details <br /> TPID- i440 Inspection Type (Fill one) <br /> Site Suffix: { ' 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: ( W� L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical AddressZ/ <br /> LZs ci- Cel i Gr Ave t�'�. l Z e:> _— <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title j ) AM O AM <br /> I / QPM ! L QPM <br /> Operational Status Tire Type Business Role Storage Type j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply)j <br /> Q Active Q Passenger • Generator Q Outdoor <br /> O ® Closed Q Altered /Il IWA <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck / <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Vew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> v Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® OtherV� e�� �����Cf <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I 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 <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 EXT) <br /> Q O - - - - <br /> 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 1 Q Other: § l <br /> Comments Ma10t'C��bYl �Le_ '�e ' `� nls [,z k l I /TD 1 C,4727Y CN A ec <br /> O� CQYI.CL�✓Yl S ���� <br /> atm s 7�1 ►� i ue i l LIL4 z no 1 a✓tCe-ei- P(Ck;hY1er CA+-4i rS 10M 2m <br /> inspection Form �nc <br /> ncluded: Q <br /> i �C_ 6W S�'6?3 <br /> Comments luded: Q — -- — - – - <br /> Business Rep's Signature Phone Number I p t r S gnature _—_ Phone Number <br /> INSTRUCTIONS ON BACK [orrect: Incorrect (, E _2� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />