Laserfiche WebLink
V1jz Lufta4LI�1. <br /> E� Waste.Tire Su )y & Inspection Repor, Inspection Report Number <br /> 1 4 <br /> W11IL <br /> State of California <br /> CTWMB181(New 04104) <br /> California Integrated Waste Management Board Survey-Form - Page 1 1 6 - 1 0 7 9 3 4 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i � � � � � � - Q t Inspection Type (Fill one) <br /> Site Suffix: { ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local Q n ^ /� If Referral,choose referral type(Fill one) <br /> Identifier: ,1 J 04-LAI 1 1 ��'�t� Q CHP Q CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> L_ <br /> — S) C_0_M< e_sLZ a� Tik'_e. I . _ 1 <br /> Physical Address a Jn EsU <br /> Street <br /> CA SD� Inspection Date <br /> � WW Time <br /> City State ZIP Code—J Time In Out <br /> Business Rep Title O AM QAM <br /> 114d � � s♦ PM Ell <br /> . 6P <br /> _ <br /> - — ��= _ I- _ __t'7_� Operational Status Tire Type Business Role, Storage Type <br /> O <br /> Tire-Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � . <br /> aActive O Passenger ® Generator. 9 Outdoor <br /> (� <br /> GPS O Q Closed ®Altered <br /> L� -L�L1 1 O Hauler O Indoor <br /> latitude <br /> O O Inactive i Truck <br /> O <br /> Lon Rude - ( I—I� Planned Q OTR ® End-Use Container <br /> g <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair O Trucking Fleet 0 Govemment O Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer O Collection .Q Crumb Rubber <br /> O Service Station O Hauler O Agriculture Q Shredder Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A i HAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 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 I 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 6 In Compliance - No Violations <br /> Q 1 Q 1 Other: § ,1 <br /> Comments — kr Q In� -jn—V`C� —� 5- Q- N - -- a <br /> <�o V Aokv'ws_br o_kus C_uxl_ ci–n. <br /> Inspection Form Included: <br /> Comments Included: �r' <br /> �; �O tV _13i <br /> Business Rep's - nature Phone Number .InspturePhone Number <br /> INSTRUCTIONS ON BACK I C rrect: Incorrect: 7,401 ( i i 2 3 62os1 <br /> � XAMP l- � ; 1 . � . <br /> White Cop :CIWM Yellow Copy:Operator Pink Copy:LEA <br />