Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> c w (N <br /> of Cdlir Il - 1088383 <br /> IM87g1(NewO ) Survey Form - Page 1 <br /> Califia Integrateo Waste M <br /> orn —gement eoartl <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID• e / Inspection Type (Fill one) <br /> Site Suffix: 3 3 3 / J 0 f (a Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type one) <br /> Identifier: �jG� J20an,,(J'�,` Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v� Inspected By Inspector <br /> o► s <br /> Phys3 � - <br /> Physical <br /> jo�e <br /> q53 Inspection Date Q 2 7 <br /> afi'e LA.., '� J l O q <br /> ,� <br /> Time In Time Out [,/ <br /> Business Rep Title 0 AM 0 AM <br /> O `� ; ( 5 '0'M 0 � { � ®PM <br /> Dkk <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> •Active ®Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indopr• <br /> O Q Inactive Q Truck N� <br /> Longitude - Q Planned Q OTR Q End-Use Q Con truer <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q 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 ®Other /"allq&j" HOWV- is �iv <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> �V <br /> V A HAULING AND MANIFEST REQUIREMENTS 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/DecalposE in Vehicle M / m / m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Dale <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 0 In Compliance - No Violations <br /> Q Q Other. § <br /> Comments 41 Spe/�l ov, * ` - � _,1I-,e no ie S -L/_ _ n"I/O wi <br /> z ch hl\oki,7e_ 4&k-lm. N[S1ff I opt <br /> tJ*GLLL1Ner ftUJ�e ftrlwhte s o,' <br /> rkc,.vt l-t. -fa b e re-u S<_d • CSL MAPa re s t f rm S rt r`:iect ►' (A nti6�OF <br /> fi;r�s h,akkLed ,Prom home-s;+z y. No v o)at'0 hs n oted ' <br /> Inspection Fonn Included:Q CQ q <br /> Comments Included:Q <br /> 9�� <br /> Business 's Signature Phone Number Inspector' Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect:X E__ <br /> j A MIPILIE1111213 62081 <br /> ■ White Copy CIWMB yenow COPY Operator Pink Copy LEA ® ■ <br />