Laserfiche WebLink
Waste Tire Su y & Inspection Report ispection Report Number <br /> Iifl State of California I 1 1127500 <br /> CI WMB181(New04104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I 0 3 ( 4D Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local `,tel If Referral,choose referral type(Fill one) <br /> Identifier: 5(, n Joc,q LioI n o ck4 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - —-- <br /> Inspected By Inspector <br /> Physical Address p <br /> 10 Fc o 4c,!r, (z,�l J - lfww✓,J�I I/ -- <br /> ^ 1 b A I'S3�� Inspection Date 1 q <br /> Time In 1 Time Out I <br /> Business Rep Title40 AM f AM <br /> S I ' 3 0 Q PM 1 0 PM <br /> j tnc,r Oil G�ctnr- T - T - <br /> -- - - - Operational StatusTire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active 0 Passenger ® Generator ! Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive S Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 Auto Repair *Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End Use Facility ENFORCEMENT STATUS <br /> m — Notice Of Violation Extension <br /> p y <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires L0 0 e <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle m <br /> 0 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / W / W m <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 114 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 0_Referred/CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> 0 0 Other: § <br /> CommentsQL <br /> ti - `(2 -CJL�— .1'��5 _ <br /> �o <br /> f10 \J'106 Com- c fsras 0T (Onwcn_- - <br /> — 4-5— IF <br /> Inspection Form Included: 0 5-T?'444 <br /> Comments Included: -. - - - Ze <br /> L- <br /> - - - <br /> - Bus Hess Rep's Ignature oNumber Insp or's Signature Phone Number <br /> - — - <br /> 1 ArptI� � 62081 <br /> INSTRUCTIONS ON BACK IN <br /> White Copy:CI Yellow Copy:Operator Pink Copy:LEA <br />