Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of C.INornia ■ <br /> tn,,.at°„Newa„°„ Survey Form - Page 1 _1 5 - 1 0 1 3 0 0 5 <br /> Canfomia integrated Waste Management Bwrd <br /> Part A-Survey _ BLUE PEN <br /> Business Profile tnspection Details ' '-1 <br /> TPID- 3(� Ins action T '1 <br /> Site Suffix: I ibl P ype (Fill one) <br /> ®Routine Q Re-inspection Q Referral Q Observation <br /> EM <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: • � {/t(n. <br /> �1J1� ll '�”-•�//1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name — —. <br /> Inspected By Inspector <br /> Physical AddressU 39 L� I�'�___� <br /> i �q D I � . �(a�sa �) - - <br /> Street r r <br /> L_ —`( yI G4 �a13_ ,—� Inspection Date O ( J 1O <br /> City [ate 1 Cede Time In Time Out <br /> Business Rep Title II O AM Q AM <br /> L C)PM 0 PM <br /> — Operational Status Tire Type Buslness Role Storage Type <br /> Tire Count(Whole/PTE) �' I (Fill one only) (Fill elf that apply)I (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger I Generator ®Outdoor <br /> I <br /> GPS Latitude Q Closed Q Altered <br /> I j I � 'O <br /> Q inactive Truck Q Hauler Indoor <br /> I <br /> Longitude _ J� <br /> Q Planned ®OTR Q End-Use QQ Container <br /> Business Type (Fill all that apply) — <br /> Auto Repair Q Trucking Fleet Q QR©treader <br /> QmtQQwrDealer Tire De ved Fuel <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 Other '- <br /> - Lg - U <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT—STATUS—__ <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decaloin Vehicle m <br /> Q Q 14 CCR§18459 -RespponsibsibEntities Entities Complying with Manifesting Requirements Data <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 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 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 001 Q Other: § <br /> ®In Compliance - No Violations <br /> Comments kI * ay, �ks d4de. 71'a=)/ �,,e�s noh4 s [sen� e o_ (�l_4 ►_s uxi <br /> �s. <br /> 4r S��c� rn f ctir��i�1eS p� o f a- <br /> ��4�5Jf L 4 MTxr-ss-fi-5r irV�S S �iSSoCI S-�I_e' 2.� u S <br /> Inspection eluded:Q `L/t,J� <br /> Comments &oes <br /> _`siness R_eWsSt nature Phone Numberature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: E 12 3 62081 <br /> White Copy CfWM6 Yellow Copy Operator Pink Copy.LEA ® ■ <br />