Laserfiche WebLink
08234040304 <br /> ne- <br /> Waste Tire Survey& Inspection Report Inspection Report Number ■ <br /> ;; Seta of CatNornla I 1 - 1088156 <br /> CNIMS 1st.Man ge Survey Form - Page 1 <br /> jai Integrated Wasta Management Boats <br /> Part A-Surye BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: / D 0 Routine Q Re-inspection O Referral Q Observation <br /> Local C If Referral,choose referral type(Fill one) <br /> Identifier: JRI�! �O o ` / C,o J„t?may, Q CHP 0 CIWMB 0 Complaint Q Educational Visit Q Other <br /> Business or Facility Name (�— Inspected By Inspector <br /> "Ay sem, �,�� 2 ( <br /> (Physical Address I ✓ l I <br /> Street <br /> Inspection Date <br /> (J <br /> I 2� ���� —J Time In Time Out <br /> City � � State Z;P Codem <br /> Business Rep Title I O AM �[]:m O AM <br /> —___— I;OPM I I I QPM <br /> L <br /> - — --- - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 1 e (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) . <br /> 0 ActiveQ Passenger 0 Generator ID Outdoor <br /> --- <br /> !0 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude - I,I i 0 Planned Q OTR 0 End-use Q Container <br /> I <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q.Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder O Other I 4 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF.ORC-EMENIT STATUS <br /> V , A HAULING ANl)MANIFEST REQUIREMENTS Q Notice Of ulolation Q E i n <br /> O O 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 0 14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> O Q 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or DCT) <br /> O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliancejo • No Violations <br /> Q Other: § <br /> CommentsiN�2�t/JJ�+e'A /�,- <br /> ouJr / �8 <br /> LZ4 �a�./I di, 114-4.40 &A p.,a s-t %� Gip �'�i•. /��'S tom---� i� f�lanQ.�t - <br /> !�_ <br /> AJ-a Wa t4—Amis D r <br /> Inspection Form Included:Q <br /> Comments Included:0 - <br /> B iness Rep's i re Phone Number Inspectors Signature one Number <br /> 62081 <br /> INSTRUCTIONS ON 4ACK CorrMill"ll Ineorreet: EXAMPLE! 111-213 <br /> ■ White Copy CIWM Yellow Copy.Operator Pink Copy LEA ® ■ <br />