Laserfiche WebLink
Waste Tire Survey & Inspection Repo"Inspection Report Number ■ <br /> ite State of California I 1 - 1143727 <br /> CIWMB181 <br /> Waste <br /> eManage Survey Form - Page <br /> California Integrated Waste Management Board <br /> Part A-Survey__-_ --- _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �3 I JI Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S t�O J 16 <br /> G[A\n COUA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ARS C-e-- <br /> Physical Address <br /> ��lla <br /> \N , <br /> G A C'63777 -- <br /> Inspection Date �j 0 ` O <br /> Time In Time Out /� <br /> Business Rep Title V O PM I o U O PM <br /> - - <br /> ---- — -�---— <br /> _—Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5. 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 40 Active ® Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> Latitude <br /> GPS Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 1*Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived 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 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 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-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Datem / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB M / <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or E)M <br /> Q i 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 li Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> O Q Other: § <br /> Comments �C11+tt'i�IAwS�� �l t�1��l1P�C�lO p�ff(9rr'flCl� (�C1��i5 C� �•nu�-�.�-�� <br /> s o s L C_" corn <br /> ,Inspection Form Included: <br /> Comments Included: � �— 1 8 <br /> Business Rep's Signature Phone Number Inspe or's Signature hone Number <br /> - - --- - y� 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect I _� V1 E <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />