Laserfiche WebLink
0��34�i <br /> rre: <br /> Waste Tire.Survey $ Inspection Report Inspection Report Number ■ <br /> ;, ClWMState 181 <br /> 1(New Survey Form Page 1 1 6 1 0 7 3 3 5 5 <br /> CIWMB 1a1(New 04/04) <br /> cellfornla Integrated Waste Management Board <br /> Part A.Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ) Inspection Type (Fill one)' <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ( If Referral,choose referral type(Fill one) <br /> Identifier. joQOj(,L�`1 �YL 1 �1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name fG �I <br /> Inspected By ' Inspector <br /> I Wfn- CrOAL <br /> Physical Address <br /> Street Inspection <br /> pection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> r m m 0 PM Q PM <br /> L--- _ _ _-_t LOperational Status Tire Type Business Role Storage Type. <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> , � ' <br /> f r . O Q <br /> Active Q Passenger Q Generator Q <br /> Outdoor <br /> GPS Latitude l0 Q Closed Q AlteredOHauler OIndoorL ®Inactive Q Truck <br /> Longitude - I ,I I I Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) 111 1 <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 /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORC-EMENT <br /> - STATUS <br /> - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q O Q Notice Of Violation Q Extension <br /> PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. C-omplianca Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 1:11 / m <br /> O 014 CCR§18459.1-Tire Program'ID Number from CIWMB <br /> O O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or F>C7] <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 C-IWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In 'a-r5--c-7e=No Violations <br /> Q O Other. § <br /> Comments N,,dAAt-- /L Jo -hye-s � ✓Cf A6e_A /t-,,, <br /> 1y0 fcYP.�J P�$�1— Gc9 m w� �o_ <br /> in mt, Tpw# No <br /> Inspection Form Included:Q <br /> Comments Included:Q I - <br /> Business p's Signature Phone Number Inspect) s gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK E X A Nt P L E 12 3 <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br />