Laserfiche WebLink
Inspection Report Number <br /> Waste Tire SuSey & Inspection Reporle <br /> ,Ij State of California <br /> CIWMB181 <br /> Waste <br /> eManag) Survey Form - Page 1 I 1 0 7 2 8 9 <br /> California Integrated Waste Management Board �'• <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile nspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ! .I I I 110 111 -71 1 I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalI —7— If Referral,choose referral type(Fill one) <br /> Identifier: f ��t� J Qa uln C oun+ 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address l a a <br /> Ph KI �� C o t���rI ��15' I -� c� - O <br /> I kns tr)ri Lt)<C,< i <br /> Street <br /> Inspection Date <br /> A )zL4 to <br /> State ZIP Code Time In Time Out <br /> Business Rep Title AMQ AM <br /> QPM m ' L� 0PM <br /> Operational Status Tire Type Business Role {Storage' ype <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> m . <br /> rGPS Latitude 0 Hauler 0 Indoor <br /> T O 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 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 ® Other I IComrQnIQ_ <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / F7 <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 14 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 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 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments c <br /> O k LA YI'12 l-n3 f) C_�'i CJCl n tr rrt e�L 4k= J�F'�S t 011 uJ t flat <br /> ( J <br /> �0L)o �� ftC1� ran �tflea r6 - 0r <br /> 117e Q �: Y t c� _ C7n - �g r�_-1_-, �C(�'j ni►�r� 115 [�C c�r'r� <br /> —c _ �. <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X Xj A'N, �1 � I 1 [2131 <br /> White Copy:CIWMB Yellow Copy Operator Pink Copy:LEA <br />