Laserfiche WebLink
Waste Tire Si Wy & Inspection Repor Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1127623 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Dela its <br /> TPID- I _ Inspection Type (Fill one) <br /> Site Suffix: , , <br /> e � } 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local , EE If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address f"/! / 3 i' f_'��et.{ ► ; +SCS <br /> Street , <br /> 4 It Inspection Date / <br /> 1—Ma P�;u O.C.-, r"11 q g)- <br /> � • Srafe /R dodgy; Time In Time Out <br /> Business Rep Title 0 AMt� r 0 AM <br /> O PM ( t''.. O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill nil that apply) <br /> Tire Count(Whole/PT y 9 ! / /1 .., <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> Latitude <br /> (jP$ 0 Hauler 0 Indoor <br /> I_ __I. _._.: O 0 Inactive 0 Truck <br /> Lon Rude 0 End-Use 0 Conlamer <br /> 9 i 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — ---- '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 / FP / 0 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 0 In Compliance No Violations <br /> 0 0 Other: § ._,......._. - <br /> :- <br /> Comments /- <br /> -, <br /> `-z����,F•? .'�i`�,,t � ��.f.�t�' YI�i�� S �._ r : i����.. �. ._ �i�i..,� _ <br /> (W-A Ul t10054 1711-e <br /> Inspection Form Includ-d: 0 <br /> Comments ta7clucaed: 0 <br /> Business Rp s Signature Phone Number Enspectos's Signature Phone Nuinber <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:0 incorrect: X v/ i. X E A W P 1 2 3' <br /> ® White Copy:ClVVMB Yellow Copy:Operator Pink Copy:LEA <br />