Laserfiche WebLink
' � t�93 ��05J044 <br /> Inspection Report Number <br /> Waste Tire Sur ,y & Inspection Report <br /> State of California FI1 1141306 <br /> ClWMB181(NewM04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> 76 ;d TPID- Inspection Type (Fill one) <br /> ID Site Suffix: 5 © 11 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local /' — If Referral,choose referral type(Fill one) <br /> 1^ . <br /> Identifier: �� "` G�V4 Q CHP Q CIWMB _Q Complaint Q Educational Visit Q Other" <br /> Business or Facility Name- Inspected By Inspector <br /> [;3!f Physical Address �1� <br /> Street I Lp b <br /> T Inspection Date <br /> CI��G� State ove Time In Time Out <br /> Business Rep . Title I OA O AM <br /> 9 Pm <br /> 49 PM <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 /> Tiee Count(Whole/PTE) <br /> ' ' ®Active ® Passenger ®Generator ®Outdoor. <br /> 0 Q Closed Q Altered <br /> GPS Latitude I I , I , �_ Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude Q Planned Q OTR <br /> I 1� �O Q End-Use Q Container <br /> - I I I I , I I <br /> I I I <br /> Business Type (Fill all that apply) .. <br /> ® New.Tire Dealer Q Auto Repair Q.Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 I I <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End Use Facility ENFORCEMENTSTATUS ##'. <br /> V� A.�„ HAULING AN MANIFEST REQUIR_1.004A S 1,9 . t „� r� . "6 . , <br /> - ®,Notice OfVlolatlon QExtens on . <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires atA � � <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers.. Compliarice Deadline <br /> Q Q '� ��• a <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 14 CCR§18459.1 -Tire Program ID Number from CIWMB *% <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> �3� (Regwr:3dfo"NOV, <br /> Q Q .14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 yearsa w" <br /> Q Q" 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q°°Referred/CIWMB Enforcement <br /> r tx . 944 <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities - x � <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ' Www"' <br /> Q$In,Compllance xNo•V¢iolations <br /> 4 4 R" 't <br /> e <br /> Q Q Other: - <br /> Comments <br /> Sec Connmen <br /> Inspection Form Included: Q �© 1 P� <br /> v <br /> Comments Included:® —391_ _ a - <br /> Business Rep S' ature Phone Number In to s ignature. Phone Number <br /> .62081 <br /> INSTRUCTIONS-ON BACK Co r ct incorrect: E�X 'Ah P I L I E .. t <br /> White Copy:C M Yellow Copy.Operator Pink Copy:LEA <br />