Laserfiche WebLink
■ _ Inspection Report Number <br /> & <br /> Waste Tire Survey Inspection Report <br /> -�' I1 - 1140973 <br /> State of California <br /> CIWMB18f(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board BLUE OR BLACK INK PEN <br /> Part A- Survey --- - - - — - — - - <br /> --- <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 5 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Cow�,rne�ru.� l Se✓v�ZeS �-� - Z7nvyl b�1i <br /> Physical Address 1 Jim <br /> 02®-10 W, lia--el ►'b ti Ave, lsv t% g – <br /> Inspection Date � J � � J C <br /> rAaAk�\, cA q536-1 Time In Time Out <br /> Business Rep Title I r1 0 AM <br /> PM 4k PM <br /> Operational Status Tire Type Business Role Storage Type <br /> rti (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , 0 Active ® Passenger ®Generator Q Outdoor n <br /> O • Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude – Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q 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 /> ------ -------- <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V q HAULING AND MANIFEST REQUIREMENTS 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 1 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EX'S <br /> Q Q <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <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: § j f { ) I <br /> Comments 1_ MIS ��/t i'a IL Jd o <br /> C�ce��►���- --- �t�- r� nt .) L�v►�gym/r'✓�1 c��_�y-� Sedy12�5—:��2o__Cc�2��� <br /> Li.Nt y_ - — �t"1_�YL-ca '✓�-� <br /> \J �- <br /> `'&A`�� �ry `y� f\ _ -1� Cc,✓'� ef�� c�,-i'�I �;>,�. �cvrn it e. ��-`7P7��l'� J�- <br /> Inspection Form Included: Q <br /> Comments Included: Q a�lt� v 4Pink <br /> Business Rep'sSigna ure PhoneNumber e Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKCorrect: Incorrect XV!■ White Copy:CIWMB Yellow Copy:Operator <br />