Laserfiche WebLink
08227040122 ■ <br /> rr1, <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Sta�,fCiG10R1d <br /> crwm (Xaw OI )asSurveyForm - Pagee 1 8 <br /> CallfomlaIntegratedWatnagt Board 8301 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPe - f 7/ O I C) Inspection Type (Fill one) <br /> site Suffix: ll ` III`�7 III ®Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �D Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Buslness or Facility Name V <br /> Inspected By Inspector <br /> �_lV i_55�o T5koF Sia c �► 13 q - To r <br /> Physical Address <br /> ��� 3► �u�a Ce�e� �e <br /> Street Inspection Date <br /> Stc�fop, of �lS�)� <br /> Cay Stale 2IP Coda Time In ___ Time Out <br /> Business Rep Title i,I I !O AM i—� , 1 O AM <br /> —- L -- _t O PM ---�- -i O PM <br /> Operational status Tire Type Business Role Storage Type <br /> The Count(WhOIe/PTE) D (Fill one only) (Fill all that apply) (Fill all that apply) -(Fill all that apply) <br /> wger• Q Generator Q Outdoor <br /> O F1.osed Q AlteredGPS Latitude Q Hauler Q Indoor <br /> 'Octive QTruck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Relreader 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 Agnculture Q Shredder Q Other I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ­ <br /> V I 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 IQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <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 EX7) <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 1 Other: § / <br /> Comments Ct 7 4 /sS c ayt+r 5io)4 /,Y) w iY(Gt,C)N "We have m Qyed <br /> h 30-7-7 w. fH-a^ l-er 4-avl e .5hcK-tVm C/o S e- TPI D # K/T M S <br /> does hot reflect hew addr-ess or rPID-4 . Xt.soech�— �o <br /> _v�f Mew <br /> �Inspectlon Form Included:Q n^ <br /> Comments Included:Q C��W <br /> Buslness R 's Signature Phone Number Inspaytor's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: (�p E X A M P L E1 111213 <br /> . White Copy Copy Operator Yellow CopOperator Pink Copy LEA ® ■ <br />