Laserfiche WebLink
08129d4d638 <br /> rrr. <br /> Waste Tire Survey & Inspection. Report Inspection ReportNumber ■ <br /> CMIMa lat(d-041H)atotee CaliforniaSurvey Form Page,1 �I 2 . 10 7 9 1 50d <br /> New <br /> callfomia Integrated W.M.Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile. Inspection Details <br /> TPID- O � r _ O / Inspection Type (Fill one) <br /> Site Suffix: I / I 0, r ®Routine Q Re-inspection Q Referral Q Observation <br /> Local /1:•- --t- ,1 - If Referral,choose referral type(Fill one) <br /> Identifier. GG(,yl J Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> ( Aod0ffts - =/ 0Physical'Address <br /> f 7,80 e-• VwMAe- +e- <br /> Street <br /> -gyp (/� `�� <br /> V I /��� I Inspection Date <br /> City /V State ZI Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> M O PM—m m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t ! f ` si0 (Fill one only) (Fill all that appy) (Fill all that apply) (Fill all that apply) <br /> ®Active ®Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> Latitude <br /> GPS _J•LI LI Q Hauler Q Indoor <br /> 1 r O Q Inactive Q Truck <br /> Longitude - I I vl - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that appy) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel I <br /> i <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q 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 /> 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 / 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/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 ®In Compliance - No Violations <br /> Q 10 1 Other: § <br /> Comments �ev..l.`f_ � nafieo( Z� o �� <br /> = � u .�f o e Ala ds ,saA /' <br /> -1 ve Sn SCi Q ao n a <br /> -ern '(10�d_ ,Fa sa No s <br /> Inspection Form Included:Q ��1l /!D <br /> Comments Included:Q ,V , <br /> Business Rep's Signature Phone Number Ins s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect:X a L: x A M P, 62081 L 1 2 3 <br /> ■ White Copy.CIWMB Yellow Copy Operator Pink Copy:LEA ® . <br />