Laserfiche WebLink
`L Waste Tire aw & Inspection RepdWspection Report Number <br /> ° CWMB 81(New04104) Survey Form - Page 1 I1 - 1088254 <br /> California Integrated Waste Management Board J a7 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � I � Lj L2—L <br /> � L!�Ll <br /> Inspection Type (Fill one) <br /> Site Suffix: I ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. — J +n1 (p - 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V _ <br /> • Inspected By Inspector <br /> Physical Address I r I / I � / %�r>;-,^) <br /> .Street <br /> s'57- <br /> o C � 0=9 <br /> / C� G 2/(, I Inspection Date <br /> Cfn, State ZIP Code Time In Time Out <br /> Business Rep Title II O AM I AM <br /> _] <br /> I L ,itjA <br /> W 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � � <br /> ® Active 0 Passenger 0 Generator 0 Outdoor <br /> I <br /> de m D O Closed 0 Altered <br /> O Hauler 0 Indoor <br /> Latitude <br /> 0 0 Inactive 0 Truck <br /> Longitude — 0 Planned 0 OTR O End-Use 0 Container <br /> Business Type (Filia tfiat app <br /> 0 New Tire Dealer le 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 0 Other <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 / 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 O -- - -- <br /> 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 <br /> [�G (l 1''6011 1 j <br /> j/n /Z f'/•• r!'/Wf1� /7 lc�� �// . �.1./.LR,s� �/�. ! f/"!/ . � �y // T(/G.�l._._A.�.- <br /> h9 (Vc. /t ,-. <br /> /zn4 S <br /> Inspection <br /> Comments Included. 0 \� <br /> Business Rep's Signature 7hone{tuber Inspector's Signature <br /> • " , i� � 62081 <br /> INSTRUCTIONS ON BACK Correct: !Incorrect: J` E 7 A� M P L. E 1. 3 <br /> �. White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> i <br />