Laserfiche WebLink
Waste Tire Sup .ay & Inspection Report- Inspection Report Number <br /> State of California <br /> CIWMB 181 04104) <br /> I 1 - 114 3 5 6 5 <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - -- --- <br /> TPID- 7 0 � Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: - -S 4'() J OXl Ce (1 ��( \A 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 O!lier <br /> Business or Facility Name 1 `�J\ <br /> Inspected By Inspector <br /> Physical Address I - 1 I SCO <br /> 0-A U 0 <br /> C� �Sa31 Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> ' 0 PM O PM <br /> - Operational Status Tire Type Business Role j Storage Type <br /> Tire Count (Whole/PTE) <br /> 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> $ Active 0 Passenger ID Generator 0 Outdoor <br /> O Q Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 40 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 0 Other 11 USS Ilk Icglv �tf� <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ' V <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> 0 I 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements DateM / 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 I (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 I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> in Compliance - No Violations <br /> 0 ! 0 Other: § <br /> CommentsIle- , S �Uj1-- -vf - oS) <br /> 'Inspection Form Included: 01 <br /> Comments Included: ®Il, —�r17u- <br /> Business Rep's Signature Phone Number Insp or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X Gfi �/J X A ,I L�112 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />