Laserfiche WebLink
Waste Tire Su"Ney & Inspection Report Inspection Report Number <br /> 61029 <br /> State of California <br /> rniCIWMB1811 Waste <br /> Survey Form - Page 1 1 2 1 0 1 3 6 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business ProfileInspection Details <br /> TPID- / r Inspection Type (Fill one) <br /> Site Suffix: '1 7 1 J1 G1 �'� ' (/ � { (#Routine Q Re-inspection Q Referral Q Observation <br /> Local !�3 If Referral,choose referral type(Fill one) <br /> r. <br /> Identifie -•�; ' �' � l �`Z�� � ;• � <br /> `" Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ <br /> i <br /> a Inspected By Inspector <br /> �7 <br /> t <br /> �.1eF- <br /> Physical Address 0 <br /> _ <br /> ,�r. <br /> -z'J <br /> Street <br /> -. . r - -) Inspection Date <br /> Citv State Zlp Cade Time In Time Out <br /> Business Rep Title 0AM AM <br /> - d <br /> - [:T <br /> 0 PM 0PM <br /> Operational Status Tire Type Business Role Storage Type <br /> 111W (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ht(U1Shoie/PTE} <br /> r^ <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O ®Closed Q Altered I <br /> Latitude ,„�„'�,•., <br /> GPS Q Hauler 0 Indoor <br /> O Q Inactive Q Truck <br /> LongitudeQ Planned Q OTR Q End-Use Q Container <br /> Business Type (t=ill 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 /> U A HAULING AND MANIFEST REQUIREMENTS - <br /> -- - Q 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 <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-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 I 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 /> ` Cry'(: �i'1.� / � 'l�Un �'� V ' G�i;r, ,' <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* incorrect: X �, +w ;Y;;,+, , , nF' h:i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />( <br />