Laserfiche WebLink
...... .. ...... .. .........-...___itJ K.J1i�e:_x-s..'1f 1'....-...:..::lu P._{ii___ -.......�J1:�.-��-...--.. ._ .._...__-_..:_:: .. .�_ ..- ___•.. <br /> WasteTire Suaey & Inspection Re orpection Report Number ■ <br /> State of California 11 - 1143547 <br /> CIWMB 181(New 04104) <br /> Survey Form - Page 1 <br /> California Integrated Waste Management Board _ BLUE OR BLACK INK PEN <br /> Part A.-Survey - — ----- - - - - - -- - -- p .. -- -- - --- -- - _ - <br /> Business Profile Ins ection Details <br /> TPID- (� I Inspection Type (Fill one) <br /> Site Suffix: ` 6 c9 3 l © ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local if Referral,choose referral type(Fill one) <br /> Identifier: ��� � '���1� �dV _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> �pp � >� n� r11 � 9 <br /> Physical Address <br /> 1� C A ��j 6 Inspection Date -7 <br /> I \►�U� _ "'' Time In Time Out <br /> Business Rep Title AM <br /> db AM j <br /> t <br /> 1 I O PM I ®PM <br /> ) � � \ - GLt�t ✓ — -- - .— <br /> (_L'���_ `�(�'�-..___ - -- -- —- - ----- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) , <br /> ® Active ® Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude ii Q Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) _ <br /> ® 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 -ENFORCEMENT STATUS — <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 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 EXT) <br /> of Comprehensive Trip Logs within 90 days <br /> Q Q 14 CCR§18459.2.1 -Submittal <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 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 Requireme�forire Deale�®r ste Tire Generators O In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: o <br /> Comments Included: - - e <br /> e�Busines s Sig ture Phone Number I e is S' n ure PhonNumber62081 <br /> _ ____- <br /> --- <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: Xrte, VI <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop :LE <br />