Laserfiche WebLink
. . .......... <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of California <br /> CIWIVIB 181(New 04104) Survey Form - Page 1 1140591 <br /> Ca Ifornia Integrated Waste Management Board BLUE OR BLACK IN <br /> PEN <br /> A-�S"=e <br /> ness Profile Inspection Details <br /> TPID- 5 0 <br /> Inspection Type (Fill one) <br /> 15 <br /> Site Suffix: Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: San JOmiulo (L)AA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> wc4c_c 01 ESCAO <br /> Physical Address <br /> CA Inspection Date 03 <br /> Time In Time Out <br /> Business Rep Title / 0 AM 0 AM <br /> 5 0 PM OPM <br /> 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 /> Tire Count(Whole/PTE) 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 0 Closed 0 Altere NA NAA <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 /> --tsiness Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used 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 /> AA Ot- <br /> -- ----- ---- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility -ENFORCEMENT STATUS <br /> V A 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 /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB (Required for NOV or EXT) <br /> 0 0 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 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 in compliance No Violations <br /> 0 0 Other: § <br /> Comments <br /> AW 14tj ck-0Ile- <br /> cos)coan, <br /> ck�,ac <br /> linspection Form Included: 0 <br /> Comments Included: 0 Business Rep's-Signature Phone Number - fin pe��sftn� <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X FE XIA MIPI LJEJ It I 2T31 <br /> ■ White Copy:CIWMB Yellow Copy.Operator Pink Copy:LEA ® ■ <br />