Laserfiche WebLink
® Waste Tire Su@6y & Inspection Reporo Inspection Report Number <br /> 1.2 M State of California 11. 27580 <br /> "� CIWMB Ca SurveyForm Page 1 <br /> (New 04104) 1 I <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J( rr Inspection Type (Fill one) <br /> Site Suffix:! 7 `s �` �(� (� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local ; If Referral,choose referral type(Fill one) <br /> Identifier: C �4L(j� L. (; �t ii f/+vl Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' <br /> � � Inspected By � Inspector <br /> ;:4J <br /> Physical Address <br /> Street I I <br /> Inspection Date ; ^ <br /> Time In Time Out <br /> Si:tre Z61ry C'�dc _... <br /> _._ E <br /> Business Rep Title 0 AM AM <br /> 0 PM 0 PM <br /> . t Operational Status 'Tire I e Business Role Storage Type <br /> p yp�` g <br /> i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count ��tOliioielPl-IE�j 2 � � ! <br /> '___. . �, �.: ' �W: �'_.. f..) ✓ Q ActiveQ ,'assenger Q Generator 0 outdoor <br /> 10 Q Closed Q Altered <br /> �PS Latitude i Q Hauler Q Indoor <br /> — — - Q Inactive Q fruok <br /> I.. Q End-Use Q Container <br /> Longitude v V; i 0 Planned 0 OTR <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 Q 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 /> - — Q Notice Of Violation Q Extension <br /> ( 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 Q 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 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 l 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> In C <br /> !1 7rl h-rj- - _ ,yr► 5 r tom'` NO 1011 c,7-r,(, <br /> Inspection Form Included: <br /> Comments Included: <br /> Business Rep's Signature Phone lumber Inspector's Signature Phone Number <br /> a ,r XI 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: `.� i 1 . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />