Laserfiche WebLink
Waste Tire S a'e & Ins ection Re D Inspection Report Number <br /> Cr ■ <br /> aEEn .State of California Y Inspection <br /> Survey Form - Page "1 I I - 3 6 1 � -7 6 <br /> },CIWMB 181 New 04104 + r, <br /> California Integrated Waste Management Board t � <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> Business Profile . Inspection Details <br /> TPID- ,1 �� Inspection Type (Fill one) <br /> Site Suffix: V '7 �' <br /> Q Routine t0 Re-inspection Q Referral Q Observation <br /> Local /� If Referral,choose referral type(Fill one) . <br /> Identifier: {,t t✓1 OCA C' U_,(.� l o L.r, t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name i -- --- . -- <br /> y� r Inspected By Inspector <br /> I t 1�a 1 I _ <br /> Physical Address J s' tt t 2- <br /> yVl1So <br /> d1 --- <br /> Street <br /> Inspection Date <br /> I 1 <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title !, f} t AM <br /> i�� � V � v 0PM ' m 0PM � <br /> Y'C.t.v�.N�rhe.,�.. (� UJi�C'+'"' 1 --- ---- <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE)Q l <br /> L) /� f (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J f l• (� Active �,` Passenger @ Generator Outdoor <br /> FFIO <br /> Q Closed `Q,Altered <br /> GPS Latitude m d <br /> Hauler 0 Indoor <br /> O Q Inactive Truck <br /> Longitude - Q Planned :) OTR (a End-Use Container <br /> Business Type (Fill all that apply) <br /> (3 New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government (5 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. (a Hauler Q Agriculture Q Shredder Q Other I J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 .0 PRC§42951•-Waste Tire Hauler Registration and Transport of Tires 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 1+4 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date -1 MC) & <br /> mo � M, <br /> / <br /> 0 , Q 14 CCR,§18459'.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 1-4 CCR§1845921'-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest'Forms and Tire Trip Logs for 3 years <br /> ---------- ----- - ....._...-- <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 14 CCR§18462-Manifest System Requirements for Tire Dealefs or Waste Tire Generators Q In Compliance - No Violations <br /> Q 1 Q 1 Other: § <br /> Commentsn f <br /> Lwd t"t F !rtlip(' t of") t i i v ' PW-0,11f tt l /rl -spe'-f i(yt Vfjf YQ C 6 to r Gi t ,P115 <br /> �c�1� <br /> CIWMB, 0114 Pckvrt kcCIPltvn (fon-) Szl_E_H9 , 1/y (U!lnwin(/ t1jos m0fed : A;;�{r��i>� Y <br /> f /� � �h <br /> --_S I .� Q h C� S ?zt�C�aC_ ij cc Ct (St d Lf -/�' -1YVk <br /> '1— <br /> p <br /> ns ection Form Included - <br /> Comments Included Q `�!. _..... '-.' �.- is-'� .V.. ..: ,� ��^ _. t �( ......------- <br /> Business Rep's Signature Phone Number Itpector s Signature Phone Number <br /> to62081 <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect: �( K . f,� i, 1-111,213 <br /> . White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />