Laserfiche WebLink
Waste Tire Survey & Inspection Repor, Inspection Report Number <br /> Stat"of 81(New ) Survey Form - Page 1 19 - 1 Q 2 7 <br /> CIWMd 181 New 04104 <br /> California Integrated Waste Management Board <br /> 55 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fitt one) <br /> Site Suffix: '0 Routine Q Re-inspection Q Referral Q Observation <br /> Local I If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> j Business or Facility Name ` 5) inspected By Inspector <br /> Physical Address ( ' 4(�►S <br /> I l0ep � d CL. AoA � <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> + 0 P 0 P <br /> Q w. t�obif <br /> Operational Status' Tire Type � Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fit(all that apply) (Fill all that apply) <br /> r ° �` 0 Active Q Passenger 0 Generator !Outdoor <br /> O Q Closed j Q Altered i <br /> GPS Latitude Q Hauler Q indoor <br /> Q � Q Inactive Truck I <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 Q Trucking Fleet Q Government Retreader Q Distnanller Q Tire Defived 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 /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> O Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> Q O PRC§42956-Registration/Decaf in Vehicle m <br /> Q 0 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date mL _1_ _J / m <br /> Q • 14 CCR§ 18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB i <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 /> O Q i 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 1 CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> _...-- ..—............._........ ..... <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dea)ers or Waste Tire Generators j 0 In Compliance - No-Violations <br /> Q O !Other: § <br /> Comments Sf„ftn tO�Z�G� 7n1/' �f�L.wi�G���aa�•/� '�YJ�B ��; — - - - <br /> � d� <br /> Aa3 i7cewt lea leJ- /.2,"Ox iz t,�" tl si Nab ?_. He li C�, or►� !S 7 e <br /> Inspection Form Included: 01 <br /> lq <br /> Comments Incfuded; /� (r[�� ! 76`-a <br /> Business Rep's Signa re Phone Num e s Signa Phone Number <br /> I _ _... : r 62081 <br /> INSTRUCTIONS ON BACK I Correct: Incorrla�t: �/ ' M P 1 f 1 i <br /> _._ � <br /> White Copy:CIWMB Yeifow Copy:Operator Pink Copy LEA <br />