Laserfiche WebLink
i <br /> i Waste Tire Survey & Inspection Report Inspection Report Number <br /> { 40426 <br /> State of�Californla <br /> t:gratoo asteManage Survey Form - Page 1 <br /> California Integralet�waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- D _ Inspection Type (Fill one) <br /> Site Suffix: 0 Routine Q Re-inspection Q Referral Q Observation <br /> I <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> j Business or Facility Name Inspected By Inspector <br /> Physical Address 6 / —Tedi l�� <br /> s -- X01 <br /> Inspection Date O 6 1 6 <br /> , Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count fflh�le/PTE) 197 <br /> f ®Active • Passenger ®Generator IS Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude _ Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill a�that apply) I <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Reireader Q Dismantler Q Tire Derived Fuel <br /> 10 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 l ENFQRCIM,. NT.STATUS_ ..._.,..-__-..._ <br /> f V Al HAULIN© ND MANIFEST REQUIREMENTS ()Notice Of Violation Q Extension <br /> Q Q 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-Regis lrationlDecaI in Vehicle m <br /> L__!� <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate / m <br /> Q , Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CfWM6 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R®q Iced fbr NOV or F)M <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Rfff�frpd f3Mms Enforcement <br /> Q 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators „ 1 <br /> !�1n ��lt><Ipl ��° Nq Nictation: I <br /> Q O !Other: § <br /> Comments GyN"�✓ �"'���n.` Dsfr�y �S Grh�• /H�- /il'�/(�wJ't�- wr�f--Ks�pC`iL. —– <br /> Jvz_>c+-\— sus <br /> ��.I l r-I� ��� ���� � Y<< o t,c�- sM����s-�s �� -�'� rc.,�.a�►c- !.�'�„v,,� _, _ <br /> Inspection Form Incl dad: <br /> Comments Inc! clod: <br /> Business Rep's Si ature Phone Number re Phone Number <br /> INSTRUCTIONS ON BACK Corlre ir(aarls ( ^X��0.,tN1IPLLt�T_�I E 2 J 62os1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />