Laserfiche WebLink
Waste Tire Survey $ Inspection Report Inspection RIPJAWn,M1 <br /> cl"SIII'Nrnla Survey Form - Page 1 ( - 10 <br /> 3 2 4 9 <br /> CMMa III t*m.." <br /> Celiromla lnlaentsdWM�Manapam.nt soars BLUE OR BLACK INK PEN_ <br /> Part A-Survey _ <br /> Business Profile _ Inspadi m Details <br /> TPID- y� Inspection Type (Fill one) <br /> Site Suffix: 31,61 © le Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral typo(Fill one) <br /> Identifier: `�p�q gyp" G � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name L <br /> Inspected By Inspector <br /> Physical AdGyss �_7�'1 c• r— � _ / / L / S_j <br /> Street Te -5 <br /> Inspection Date <br /> ^^ X153"7'7 <br /> Cliy ►�G/y C tate 71P Code Time In Time Out <br /> Business Rep Title m m OPM m m 0 PM <br /> 0 <br /> 'Operational Status!Tiro Type I Business Role Storage Type <br /> j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I i/��� 1 <br /> 0 Active ®Passenger *Generator ( *Outdoor <br /> Q <br /> GPS Latitude { _ I 0 Closed Q Altered Q Hauler Q Indoor <br /> Q Inactive 0 Truck <br /> Longitude I O a Container <br /> 9 – � .� � i Q Planned o OTR ®End-Use <br /> Buslness 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 ®Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFO_R_CEMENT STATUS.__.T <br /> V A 1HAULING AND MANIFEST REQUIREMENTS ®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-RegistratioNDecal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data H.6 F;�,] <br /> I <br /> Q Q 14 CCR§16459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or E)M <br /> Q Q 14 CCR§16459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CiiWMB Enforcement <br /> ® Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities I......_ <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> Q Q Other. § <br /> c nts _ <br /> .- <br /> Inspection Form Included:Q <br /> Comments Included: ` w�r � — <br /> Business Rep's Signature Phrone Number dors Sign a Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: @1 ElklAIMIPILIE1 1112131 <br /> . White Copy.Cl W MB Yellow Copy Operator P,nk Copy.LFA ® ■ <br />