Laserfiche WebLink
Waste Tire Survey & Inspection Repos i. Inspection Report Number ■ <br /> I California <br /> 1( eCMB Nw04/04) SurveyForm - Paige 1 Il - 1143735 <br /> California Integrated Waste Management Board J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> j TPID- kA <br /> � - O � Inspection Type (Fill one) <br /> Site Suffix: q Ip 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(Ao J 0aqu.i(� C( `�1"1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name \J Inspected By Inspector <br /> I <br /> Te- c,\,1)0IO1C,5 anCki('5 3 � - 4 d � � <br /> I <br /> Physical Address <br /> n <br /> i <br /> Inspection Date , b a <br /> Ce��� C CA 85231 <br /> Time In Time Out <br /> Business Rep Title `� O AM O AM <br /> C0 <br /> ` 1 1 '� l�2 ' J V 0 PM I le PM <br /> \10 DJV b StJ�,p.Q ASit _ - - <br /> - --- - - -- - - - --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> q 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> D Q Inactive ® Truck i <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill 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 Other �(LLk f ��;`f <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 /> 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 <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments I 1 \ <br /> 'Inspection Form Included: Q fa ca0 1 <br /> Comments Included: � CCI+ �C�� � � —�-`—'_Ui�� ' �)I U <br /> Business Rep's' S' n turi2 phone Number Inspec 's Signature -Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/I �pr� a 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />