Laserfiche WebLink
0925.9040653 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIW B California �I 1 - 1127626 <br /> CIWMB 181IteManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN . <br /> Business Profile Inspection Details <br /> TPID- �1 Inspection Type (Fill one) <br /> Site Suffix: �'TJ J �L� � - [�F/j O P O O <br /> l ��_ Routine Re-inspection Referral Observation <br /> Local —� If Referral,choose referral type(Fill one) <br /> Identifier: I— Q - IO CHP O CIWMB O Complaint . O Educational Visit 'O Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physical AddressSe <br /> Street <br /> Inspection Date <br /> City K Stafe 210 Coce Time In _ Time Out <br /> Business Rep Title ---- T--I I Q AM I — <br /> IIDIlJ�U O PM 0A 1 . (1 L I �� Q AM <br /> ® 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 Outdoor <br /> PSLatitude <br /> — _ I 1 O O Closed O Altered <br /> G <br /> Hauler Indoor <br /> O Inactive ® Truck <br /> LongitudeO Planned ® OTR <br /> - i O End-Use O Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer O Auto Repair 0-Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler ® Agriculture O Shredder O Other <br /> I 1 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ,ENFORCEMENT�,STATUS <br /> ;V A ,HAULING AND MANIFEST REQUIREMENTS. ; ;W�. ,< + <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ,QNotice Of violation* 'O F-�xrpslon „ <br /> PRC 453-Contracts with Registered Waste Tire Haulers. <br /> O O § 29 g Compliance Deadline r a <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m . <br /> O O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for PIONbr DCT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years r „px <br /> ,,,., m <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O,Referred I CIWMB Enforcement <br /> O O 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 Violation s- <br /> O O Other: § a= <br /> ,., a <br /> Comments C � I�` T�tit.S f o ,�L�I ( trL Vj Q,5 <br /> u5 aCt�f _G�25 Pr� � �� `TOS` . <br /> �� tMGL i; S iewrd - ()Alaq6t Ye_ s+tX uZ�d- <br /> AIC) vi a <br /> Inspection Form Included: Q r <br /> Comments Included: O - �RepW'§ <br /> - v ���� - ca <br /> �� v ��� <br /> menature Phone Num er Inspector ignature Phone Number <br /> INSTRUCTIONS ON BACK C rrec :Incorrect: ( j� EIIX A M P L E 1 Z- 3 62081 <br /> White Co :CIW Yellow Copy:Operator Pink Copy LEA <br />