Laserfiche WebLink
08038�e03� 1 <br /> eea: <br /> Waste Tire Survey & Inspection Report inspection Report Number <br /> !` CrVVMB181(Nate of r0ia Survey Form = Page 1 1 6 . 1 Q 7 9 4 2 l <br /> CONMB 181(Naw 04/04) <br /> Callfomia Integrated Waste Management Board <br /> Part A-Sut V BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site suffix: Z 3 3 ®Routine Q Re-inspection Q Referral Q Observation <br /> Local �_� If Referral,choose referral type(Fill one) <br /> Identifier: S�t,. oc� '/� C `a" 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name -- ---- <br /> Inspected By Inspector <br /> Physical Address / <br /> L �aca�t-1�I <br /> L-13.25 Cow+trv,xrcu.. ��• 1 <br /> Street <br /> Inspection Date <br /> L <br /> City Mate Zip Code <br /> Time In Time Out <br /> -- <br /> 0 AM 0 AM <br /> Business Rep Title m'm®PM m'm a PM <br /> - I Operational Status Tire Type .Business Role Storage Type <br /> Tire Count(Whole/PTE) I a i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger (j$Generator 0 Outdoor <br /> GPS Latitude I I l I _I_I f I ID O Closed Q Altered GPS <br /> O <br /> Hauler Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - J - Q Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer Q Auto Repair• O Trucking Fleet Q Government 0 Retreader Q Dismantler O Tire Derived Fuel <br /> A Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station . ®Hauler 0 Agriculture Q Shredder Q Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use FacilityENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Notice Of V1 Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompIla nce Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required!or NOV or F,CT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§1B460.2-Manifest System Requirements for Registered Waste Tire Haulers Referred I CIWMB Enforcement <br /> 0 O 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 /> Q 1 Other: § <br /> Comments <br /> _ ��r4.�tiQ t'vlS•f�ca�T!-'�'�c� 'f-taiS aLOa�.+. "-uSr�,�.r—�yJ �;..Da.! �`S f�tO <br /> Leiee), L',P SG endo P.o t In <br /> CCL . AO WS/yj _ _ _ _ .94 _ <br /> I <br /> (Inspection Form Included:Q <br /> Comments Included:Q t�7�C ►— - ./_'/ a y6'8-Ob <br /> _ Business Rep's_Signature Phone Number Inspector's Signature _ Phone Number _J _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> • �)x a +� p � �� � z � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy.LEA <br />