Laserfiche WebLink
Waste Tire Survey& Inspection-Report Inspection Report Number <br /> 'State of California ■ <br /> Cgrated (New 04104) Survey Form - Page 1 14 - 10 7 9 3 6 7 <br /> California Integrated Waste Management Board <br /> Part A Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> Inspection Type (Fill one)Site Suffix <br /> TPID- ' 9 �Jl g HD • Routine Q Re-inspection .Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: __�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Pbys-Fic-ai—Cdress �V <br /> i—�O-1_G� o�m-► _e <br /> Street <br /> M �,�j Inspection Date <br /> L'—`�6�C� "— DJ Time In Time Out <br /> City otate ZIP Code K <br /> Business Rep Title 0 AM 0 AM <br /> 11�1O V m PM E141 ® PM <br /> I-- ahs�,\,s_�.r�j�1c,�.�__�t O�vV��— -� <br /> Operational Status Tire Type Business Role Storage Type . <br /> I }� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE). f <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude I i 1 D ® Closed Q Altered <br /> GPS � � l � _ Q Hauler Q Indoor <br /> --J - --- Q Inactive Q Truck <br /> j Q Planned Q OTR Q End-Use Q Container <br /> Longitude - I <br /> Business Type (Fill all that apply) III I <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 /> 0Service Station QHauler QAgriculture QShredder Q <br /> Other <br /> I I <br /> Part B- Inspection of Waste Tire Dealer, Generator; Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V = HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 1 C-IWMB 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 C-ompliance - No Violations <br /> Q Q Other: § <br /> Comments on � - � <br /> I)OAtc 1�o U►�� �'L�Cy- <br /> CDr1GP.�'rl <br /> Inspection Form Included: Q <br /> Comments Included: 0einature <br /> Business Rep' ignature Phone Number In Phone Number <br /> F, P62081 <br /> INSTRUCTIONS ON BACK orre t: ncorrect: X P L E . f 2 3 <br /> ■ White C I MB Yellow Copy:Operator Pink Copy:LEA <br />