Laserfiche WebLink
® = Waste Tire "ey & Inspection Rep" Inspection Report Number . <br /> CIWMB811fornia <br /> (New04104) Survey Form Page 1 I 1 - 1127938 <br /> California Integrated Waste Management Board Y - �J <br /> Part A- Survey - . BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - - <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: J p� �y j 0 I Routine Q Re-inspection 0 Referral Q Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: S(A� J Q�i1 ut n CO u n�� O CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> S(1 \ _ <br /> Physical dA dress Gen O I Es(off 0 <br /> 1 au (3 N _ Ya-�Cry-)Ae Ave, <br /> rr CA (] GJ /3)7 Inspection Date <br /> _1 Time In Time Out <br /> Business Rep Title O AM 1 O AM <br /> �S Uln �Gl.ns�.1� AcS15�' . O 0 PM � `� � 0 PM <br /> - - -- - - - - -- --- -�- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active ® Passenger ® Generator Q Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude � Hauler I�� ® Indoor <br /> O 0 Inactive ® Truck <br /> Longitude - Q Planned OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 0 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 19 Hauler Q Agriculture Q Shredder Q 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 /> i Q Notice Of Violation � Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q � Q § 9 Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> 00 ' 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O i 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 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 Compliance - No Violations <br /> O OOther: § <br /> Comments <br /> Vf <br /> Set CO <br /> Inspection Form Included: Qi <br /> Comments Included: �; �� �C'� `i � �� ✓� D <br /> s112s Rep's Signa ure �hene Number In�ISure Phone Number <br /> INSTRUCTIONS ON BACK Correct. Incorrect I �1 l 3 62081 <br /> - ------ - __ " l, -.. <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C y: © ■ <br />