Laserfiche WebLink
08038040303 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of 181(Nmia Survey Form - Page 1 1 6 - 1 0 7 9 4 1 0 <br /> CIWMB 181(New 041114) <br /> eellfomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � m Inspection Type (Fill one) <br /> Site Suffix: I O�Z� t l'/ I O l ®Routine Q Re-inspection Q Referral Q Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: J QQ lAlf�l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical e� w.,Address <br /> 5 FoT 14MJ,� &e(-�&j <br /> s-M 2_ Y+'tPN <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM Q AM <br /> �C.L k"taf m m O PM m m O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 1 i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f '7­ <br /> 0 Active (a Passenger ®Generator Q Outdoor . <br /> 10 Q Closed Q Altered <br /> GPS Latitude- I-�—I,L-_ I--I I � Q Hauler ®Indoor <br /> -_ 0 Q Inactive Q Truck <br /> Longitude I I Q Planned Q OTR Q End-Use Q Container <br /> - [ J-_I I _ 1 1 _ <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer ®Auto Repair Q Trucking Fleet Q Government Q Retreadet Q Dismantler Q Tire Derived Fuel <br /> Q used Tire Dealer Q Auto Body ®Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility KIENF.61ROEMiENT STATUS <br /> V A HA LING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 , 1:11 <br /> Q Q 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2:1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O --- <br /> 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 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18,462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance No Violations <br /> 010 Other: § <br /> Comments a `, '- <br /> _ Nc� � - �/�yV <br /> CIA <br /> Inspection Form Included:O - <br /> Comments Included: <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X A M P L � 1 :2 3 62081 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />