Laserfiche WebLink
Inspection Report Number <br /> Waste Tire SL ey & Inspection Repor <br /> State California Survey Form - Page 1 Il - 1088274 <br /> CIWMBB 181 New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPI D- ' O IS I _7K <br /> I 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: c o o nt <br /> D�tU10 � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name (fInspected By Inspector <br /> ,-t()rl 1 t <br /> o(I(A II <br /> Physical Address �� - I O ' Kf I -tt4qn L,,tC<4 <br /> ZuU2. F , Bcgrnrncc Ln. I <br /> Street <br /> Inspection Date Q Z <br /> CA 95.210 I <br /> State ZIP Code Time In Time Out <br /> Business Rep Title (DAM [T Q AM <br /> O PM —.. O PM <br /> j�ennt� Ter)tf knk P rvs M - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active Q Passenger Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I I , I I I Q Hauler Q Indoor <br /> 1 O Q Inactive Q Truck <br /> Longitude - i� , Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 ® 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 <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 <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 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/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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments 9 0,-kf IyAk In,_Vect►onIj�kr�(_),r 1Qd t� �1 6CdL t ollo V, a r_IOl <br /> `�p(>Cv1r.. r-,7 '�1'fEs ''�-�'o re��c (;Yl-st�'e -_ F�iC11►�y La54� t�Q'�C 1zec.oV�T J <br /> for �) Af+Z A Ve fLt"noyal tram PrerAI EDS' inn + e:, y w-l: A Pon <br /> tv�T 1\10 \110c�t o n c,r r`<_� .o v c r _ — - <br /> Inspection Form Included Q ,. <br /> Comments Included. 0, <br /> Business Rep's Signature( Phone Number In ec ors Signature;'�/ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X � � I A M p L I= ' 1 2 I 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />