Laserfiche WebLink
09182040.192 <br /> =�r ,, Waste Tire Survey & Inspection Report Inspection Report Number <br /> e� <br /> Ialitornla <br /> CSurvey Form - Page 1 13 - 1 0 7 9 3 6 6 <br /> IWMB WMB 1 781(Naw 04/04) <br /> California Integrated Waste Management Board - <br /> Part A_- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ___ q I Inspection Type (Fill one) <br /> Site Suffix: L 1 3 6 8 O ` Q 0 Referral Q Observation <br /> Routine Re-inspection <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: I � ��� C%�r�L O CHP O CIWMB Q Complaint 0 Educational Visit O Other <br /> Business or Facility Name _( Inspected By Inspector <br /> yS.P n? c� ov Zr,atu�r�esu _ 1 , A� m I <br /> dress <br /> Street q <br /> (�jy� Jr3 Inspection Date <br /> city� - — 1! Stat� ZIP Code Time In Time Out <br /> Business Rep Titlern <br /> E <br /> O AM O AM <br /> aV v ® PM ( ® PM <br /> ll <br /> Operational Status Tire Type Business Role . Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ' ® Active O Passenger ® Generator ®Outdoor <br /> I I --IO O Closed O Altered <br /> GPS Latitude i I I O Hauler O Indoor <br /> Q Inactive Q Truck <br /> —..-—— --- --I ----- <br /> O <br /> Longitude — I I I I I 4 I Planned OTR End-Use Q Container <br /> Business Type (Fill all that apply) 111 I J <br /> Q New Tire Dealer O Auto Repair O Trucking Fleet 0 Government Q Retreader O Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer . O Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station O Hauler O Agriculture Q Shredder ® Other 1�3 6A7_b7_j{___jh0.01-0 h <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST-=REQUIREMENTS <br /> O ' 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation O Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O .O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> O Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 Q 1 Other: § <br /> Comments <br /> yff <br /> jam, �,-u—�'-- - <br /> - L t�4 -C _ <br /> Inspection Form Included: Q <br /> Comments Included: O <br /> Business Rep's Signature Phone Number InMORS ture Phone Number <br /> INSTRUCTIONS ON BACK Co ect: ncorrect: ( X A Mj p E I 1 2 3 62081 <br /> ■ White Cot.CI Yellow Copy Operator Pink Copy LEA <br />