Laserfiche WebLink
EEIE. Waste Tire Si fey & Inspection Repor Inspection Report Number <br /> 888. <br /> AA81 State of California CIWMB 181 04104) <br /> California Integrated Waste e <br /> Management Board Survey Form - Page 1 Il - 1127523 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Q Routine Q Re-inspection ® Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SaV1 �' Q CHP Q CIWMB ®Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ' J i {-� A,100 <br /> Inspection Date / j / fti <br /> � Com. ��a(� 11 <br /> Time InTime Out <br /> Business Rep Title �j , O AM Q AM <br /> L ' �1 C d PM � � E� ®PM <br /> -- — - -{Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) V (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ®Generator 4b Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> D Q Inactive ®Truck <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 0 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 I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> ----- - --_ 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 m <br /> Q ! Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date I I I , / <br /> ® j Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB 111 (((... III 111 III <br /> O I Q 114 CCR§18459 .2.1 -Submittal of Comprehensive Trip Logs wwithin (Required for NOV or EXT) <br /> 90 days � <br /> Q 14 CCR 18459.3-Retention of Comprehensive Tri Logs for 3 ears <br /> Q Q !14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred f 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 i,Q In Compliance - No Violations <br /> • Q Other: § / 1 c SJr _ <br /> Comments <br /> U� <br /> Inspection Form Included: 6 - <br /> Comments Included: J 6.� - — - --ea -- - <br /> I `; sl es s S r4" Phone tuber In tor' Si nature Phone Number <br /> INSTRUCTIONS ON BACK r Cor ncorrect: X ' $ p 62081 <br /> White Copy B Yellow Copy:Operator Pink Copy:LEA <br />