Laserfiche WebLink
® Waste Tire ;"Arvey & Inspection Reps. It Inspection Report Number <br /> mor State of CaliforniaC WMB 181 04/04) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 I 1 1140662 <br /> ^,qt A- Survey BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> I PID- Inspection Type (Fill one) <br /> ® Routine Q Re-inspection Q Observation Suffix: "l <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: -SCLV\ "Jf ckct eckl1\,IL / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name l <br /> Inspected By Inspector <br /> Physical Address <br /> `lC0 <br /> L J l Inspection Date <br /> eLVt rC.c C i� C ��:5�, ` l <br /> � Time In Time Out <br /> Business Rep Title y O AM Q AM <br /> l <br /> (RPM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) A (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ® Generator Q Outdoor <br /> - — --- -- --- -- -- 0-- ® Closed Q Altered <br /> GPS Latitude V Q Hauler Q Indoor <br /> D Q Inactive Q Truck r~ <br /> Longitude - Q Planned ' Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> . Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® 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 /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 Date / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q - - - - <br /> 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 <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 1.n.�-tz_ l SI z_� J�� r_ v► `f, i ate:,L_.-_ c, s �>� <br /> ccs v_ <br /> _R -c,_ /CLY r e-M-P -t-(-- LZ, ' S 1Zsej4 fi,> _ --ka mac k 'i,••,e s e- <br /> ,..-pection Form Included: 6 <br /> Sr <br /> Comments Included: Q 3'' <br /> QQ- 6S�16� - <br /> Business Rep's Signature Phone Number Insp is g ture Phone Number <br /> INSTRUCTIONS ON BACK Correct:11111, Incorrect X E )C A M P I (� f 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />