Laserfiche WebLink
` Waste Tire Survey & Inspection Repoi Inspection Report Number <br /> State B California I 1 - 1140599 <br /> CIWMB181ornia /04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> BLUE OR BLACK INK PEN <br /> P-,t A- Survey- <br /> ess Profile Inspection Details <br /> B e y Inspection Type (Fill one) <br /> 5 Site Suffix: ( "i L ® a Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localrr , If Referral,choose referral type(Fill one) <br /> Identifier: �n �(' � W�.l�� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (� n Inspected By Inspector <br /> Physics Addre40 <br /> jo <br /> Uj <br /> Inspection Date ' I 1 0 <br /> Time In Time Out <br /> p <br /> Business Rep Title 1 0 AM 49 AM <br /> 0y l 1 O PM S 0 PM <br /> D'Qin 1a ) ) r^ r —- -- - - <br /> V — Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 23 <br /> Tire Count(Whole/PTE) <br /> Q Active ® Passenger Generator � Outdoor <br /> O Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> lew Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader Dismantler Tire Derived Fuel <br /> >ed Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A I HAULING AND MANIFEST REQUIREMENTS 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 /> 00 . 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / FT] <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 (Required for NOV or EXT) — <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/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 In Compliance No Violations <br /> 0 0 (Other: § _MCA_ <br /> —_ 1 <br /> .Cff� <br /> CommentsOSf`YLivy1Z <br /> t <br /> Jt�c•Q,�ca-�1�,��� �- ��t.S f1Q--ems'- - - - <br /> ection Form Included: O ©tel �` 7 <br /> Comments Included. Inspe is Si nature hone Number <br /> i usiness Rep's Signat� ho�N�ber/ P_ rJ <br /> INSTRUCTIONS ON BACK Correct: Incorrect X A M P �1 1 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />