Laserfiche WebLink
, <br /> � = Waste Tire Su4ey & inspection Repo.r ; Inspection_Report Number ■ <br /> `G CIWMB 811(New 04104) <br /> California Integrated Waste Management Board Survey Form - Page 1 fornia .4 - 1 3 0 :4" <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> l j - / J - Inspection Type (Fill one) <br /> Suffix: / c� 5101 S Routine Q Re-inspection 0 Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) - <br /> Identifier: inn O CHP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Businesf] <br /> s or Facility Name �} Inspected By — Inspector <br /> I Ali Ti eytA.i1d T ril ` ;• GE <br /> Physical Address <br /> C - d � <br /> Street - <br /> r-•, Inspection Date <br /> City State ZIP Code Time In Time Out n <br /> Business.Rep Title ' AM i <br /> 0PM ' m QPM <br /> 3 Assn , �Vy i12.r- - - - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) f Lik-OU <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Ih11J I� I(& Active Passenger Generator (n Outdoor <br /> O O Closed 0 Altered I t <br /> GPS Latitude m Q Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - O Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer (D Auto Repair 0.Trucking Fleet O Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body O Car Dealer Q Collection Q Crumb Rubber <br /> I <br /> Q Service Station Q Hauler O Agriculture Q Shredder O Other I I <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> p V ; A 'HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2:1 :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 /> Q 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> 1010 1 Other: § // [ ( / J <br /> Comments i"1 U7 Qi)t <br /> [12 W,4fig (,l 'z'(Arr - <br /> > t <br /> ja t/•ioh+1y?1 S '00-1-rd <br /> I <br /> Inspection Form Included: �_ r <br /> Comments Included:0i ' i / .."✓1 �`ra" i ..1 - -._... . __ __ -- J' -.:.. <br /> Business Rep's Si nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: jEjXj.AjMjPjL 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> V <br />