Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> , eabnvreMear ter •le..C1111 a trual Survey Form -Page 1 14 . 1 01 3 0 3 <br /> J n <br /> 7•:-slilomia Intiyrabd Wane Manage wd eoW <br /> _ BLUE Q&WA INK PEN <br /> Part 7� <br /> Business Pro to Inspection Details <br /> TPID- q Inspection Type (Fill one) <br /> Site Suffix: f 6 `� lJ 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> LocalH Referral, <br /> sichoose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name inspected By Inspector <br /> �w�d i <br /> Physical Address <br /> i 47899 S. �� ' I <br /> Street <br /> ` Inspection Date <br /> /V(�e�a � (?,63,3b <br /> (City / tate 7_!r5 ode Time In Time Out <br /> Business Rep jq����� , �./ Title AM <br /> ;?amvr �-J�y�� r m•�0PM OPM <br /> — -- - � Operational Status Tire Type Business Rale Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f r l <br /> 0 Active I ®Passenger ®Generator 0 Outdoor <br /> -- —t O 0 Closed (, ®Altered <br /> GPS Latitude 0 Hauler 0 indoor <br /> —' Q Inactive ®Truck <br /> 10 <br /> I®End-Use 0 Container <br /> Longitude - I 0 Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> L0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber ,, <br /> t�Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other t y,((���/ <br /> V( I i <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violatlon 0 Extension <br /> 0 1 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-RegistralionlDecal in Vehicle <br /> 0 0 '14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m m/m <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days —� (Required for NOV or om <br /> 0 0 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 I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> _not a_0Cp_t P3hA -mss. l l�ink• d sate- arch <br /> �fir�r <br /> s <br /> a Z <br /> Inspection Form Included: <br /> Comments Included:® 0 <br /> Bu as p's Signature hone Number Ins p clots Si ure __ Phone Nu Number <br /> �-�/ -- <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A MP L Es 1 2 3 62081® ■ <br /> ■ White Copy.CWW6 Ytilow Copy:Operator Pmk Copy.LEA <br />