Laserfiche WebLink
r $ Inspection <br /> Report Number <br /> Waste Tire Su ey & Inspection Repor <br /> State of California <br /> tgadeeMangeCalfomaIn181(New <br /> ament Board Survey Form - Page 1 L-J-1 }fi <br /> Part A Survey BLUE OR BLACK INK PEN <br /> 7 t tIl0fV� ✓� y� �1 � r�umvt��n�t�h.A�w.��e�ra ���✓��^Y �14��, <br /> TPID- /1 �.7 � Inspection Type (Fill one) <br /> Site Suffix: t � ,' ! (� j 4 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local (I r If Referral,choose referral type(Fill one) <br /> Identifier: <br /> 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business`Qr Facility Name i Inspected By Inspector <br /> n C i <br /> Physic ald� dress i - y '7—--- ---------------- LJIll-F ' <br /> Street J <br /> .,�- ` Inspection Date � •� / ���� / ��•, �� <br /> City State ZIP Code Time In _ Time Out _ <br /> Business Rep Title Q AM Q AM <br /> ��QPM � � �- --� QPM <br /> Operational Status r �� Business Role <br /> �� `��iy (Fill one only) ( !( Ilgi � (Fill all that apply) <br /> N <br /> ( � <br /> t. ® Active ti Generator <br /> O Closed <br /> GPS <br /> Latitude <br /> � r' �C Hauler I � <br /> 0 f <br /> i�r <br /> 10 Inactive t ) <br /> Longitude - 0 Planned O'OTR 0 End-Use 0 aritaI r <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ® Other i <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AN'Di MANIFEST REQUIREMENTS; <br /> --- - - 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m IE ID <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 O § <br /> 114 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> Comments <br /> RUt ( l <br /> U 10r r` i:Yl !?f l ;t C Ts C) <br /> I <br /> f.TUv�rl / r�,r!;� ✓>.� � 7;Ilk' �1` ���.P�_._�I�� �y' ���;_P <br /> I; <br /> . _o OTl .� v�� 5,�e � �t -t� f �prP r�fE� 7 , �ol�r 1�►P�p�j,. <br />} <br /> A ,l ,r ; 1:, �. r /r- 0_1 001 <br /> Inspection Form Included: Q' , <br /> Comments Included: 01 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _ <br /> INSTRUCTIONS ON BACK Correct; Incorrect: X° \/ , i�"�. 62081 <br /> 'D a I IW. o_ <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />