Laserfiche WebLink
09210040.241 <br /> =`eo_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> � CState of California y g I 1 1088066 <br /> CIWMa 181(Now04104) 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- Wffl <br /> FO <br /> aType (Fill one)Site Suffix: q[ IJ55Inspection <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local01 If Referral,choose referral type(Fill one) <br /> Identifier: I se, 1 W n Wux)i Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> � P Y Inspector <br /> Physics ddress�— JE9 <br /> h-to—ILi <br /> tre <br /> Or . -D n Inspection DateU75 <br /> n I O <br /> V �.b�, me <br /> City State ZIP Cope <br /> Time In Time Out <br /> Business Rep Title I �j AM g AM <br /> ! I IO- -J �-,O PM �_I I . JI OI O PM <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 O Passenger IS Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude . : Q Hauler a Indoor <br /> O Q Inactive 9)Truck <br /> Longitude - i j 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 • Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other i <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 DC7) <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 In Compliance No Violations <br /> Q Q Other: § <br /> Comments — <br /> nb V�O`avcs_Of Inspection FormIncluded: Q r T1 <br /> �] <br /> Comments Included: Q 1 <br /> 1 <br /> Business s S' ature� Phone Number Insp dors Signature Phone Number <br /> INSTRUCTIONS ON BACK Co rest: correct: X hh P 'L E 11 [2 3 62081 <br /> White Co .CIWM Yellow Copy:Operator Pink Copy.LEA <br />