Laserfiche WebLink
A ..,.,..s .A. <br /> Waste Tire Su -%y & Inspection Repo Inspection Report Number <br /> � 7TLD <br /> Stateof Survey Form - Page 1 Z .Z Q - � <br /> CIWMBB 18181(New 04/04) <br /> California Integrated Waste Management Board -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br />} TPID- -y - Inspection Type (Fill one) <br /> Site Suffix: ' ` ' 0 Routine Q Re-inspection 0 Referral (a Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 70a LA 0 C.Quni O CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 7 C-es uftl ce Ls I <br /> Physt al Address - t <br /> � Kostla r_ Lucas I <br /> I Z-4�- 1, �.. woa ?_r (A <br /> Street <br /> Inspection Date <br /> i -AUC. torn CA (IS 2clsI <br /> Citv State ZIP Time In Time Out <br /> QPM QPM <br /> � <br /> Business Rep Title Q AM Q AM- m ' <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PT <br /> a (Fill one only) (Fill all that apply)' (Fill all that apply) (Fill all that apply) <br /> QActive O Passenger ® Generator O Outdoor <br /> 7 Q Closed 0 Altered <br /> GPS Latituded I 1 Q Hauler O Indoor <br /> O ® Inactive O Truck <br /> Longitude - Q Planned O OTR O End-Use O Container <br /> M=6 (Fill al h't app Y <br /> (a New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer 0 Collection Q Crumb Rubber <br /> O Service Station Q Hauler Q Agriculture Q Shredder O 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 /> O O Notice Of Violation 0Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> 0 O 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 <br /> Q In Compliance - No Violations <br /> O 0 Other: § <br /> Comments 1 1 t <br /> 1lo n9c,r Ca_ �_Q C]I Ot n CALFy C i i t I:C_ <br /> �k6� or 1,, - '-cam <br /> Inspection Form Inc►uded: <br /> Comments Included: <br /> Business Rep's Signature Phone Number Ipector's„Sgnatur Phone Number <br /> - __ -- - - 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E X ,+� hit P f F <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />