Laserfiche WebLink
Waste Tire Sur iy & Inspection Report ._ Inspection Report Number <br /> '•��-, State of California - <br /> California Int gated'WaseeManagement Board Survey Form - Page 1 i 5 - 10 1 6 5 6 3 <br /> Part A - Surve _ - BLUE OR BLACK INK PEN <br /> mom ILL_ <br /> TPID - -� - �) Inspection Type (Fill one) � <br /> Site Suffix: LL 9 3 3 I W �+ 1 Routine Re-inspection Referral <br /> 0 P 0 0 Observation <br /> Local If Referral, choose referral t <br /> Identifier: l (/�IPr YPe (Fill one) <br /> %•7 �'� oo � w% 0 l Not rll j 0 CHP Q CIWMB Q Complaint Q Educational Visit Other <br /> Business or Facility Name d Inspected B <br /> P y Inspector <br /> Physical Address J 1VIM <br /> Street <br /> `/ � , ' `I ^•�^ ` . _ r — Inspection Date (" / <br /> uIry State /ZlP Code Time In Time Out <br /> Business Rep Title i - Q AM 0 Am <br /> __ __ __ _ QPM Q PMJ <br /> FIJI one only) - TireT <br /> Operational Status ype �usiness Role I St ge Type <br /> Tile Count (Whole/PTE) F-- Y) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> J Q Active (:I Passenger 0 Generator Q' Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude - iT 0 Hauler 0 Indoor <br /> 0 Inactive Q Truck <br /> LongitudeF <br /> F 0 Planned 0 OTR 0 End-Use 0 Container <br /> Iff <br /> 0 New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Re treader 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 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC § 42951 - Waste The 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 1111:110] <br /> / / <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 a 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 I CIWMB Enforcement <br /> 0 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 1 Other: § <br /> Comments <br /> RY)7G <br /> CdG� / PS ' . �117ff �'(i � yil ,1ir (� ; rA S /c ✓ icie of , , , ✓ Iti <br /> Inspection Form Included: <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspecfor s Signature <br /> - 62081' " <br /> INSTRUCTIONS ON BACK Correct: * Incorrect: X r_ 3 <br /> ■ White Copy: CIWMB Yellow Copy Operator Pink Copy'. LEA ® ■ <br />