Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Survey & Inspection Repoli r ■ <br /> •"' CMBate of;11( (New 04/04) Survey Form - Pa/uye 1 I 1 - 1143733 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey_-_ __ -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 O O 5 � O ' Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 5 44 ) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _7 Inspected By Inspector <br /> u cr nuk10 n,% 1 I <br /> Physical Address31 _ Ren "J� <br /> �� �� �7�3 Inspection Date � � O <br /> P 1 Time In Time Out <br /> Business Rep Title O AM O AM <br /> 11 O PM O PM <br /> - <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 /> Tire Count(Whole/PTE) <br /> 19 Q Active Q Passenger Q Generator Q Outdoor <br /> --- - - —- -- - D 40 Closed Q AlterLatitude d�� ,V/� NIA <br /> GPS i Q Hauler Q Indoor <br /> D Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> i <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 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS 1 <br /> j 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 I <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 iQ 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 \ N 'U v 1 �� � �J1 I <br /> t�1-tL���-'1-�t7n5 �- ��CF�S---fj_T_—�-(9•(�c�n. <br /> N o�c'•- k. F 6k_o t; mus t11P S <br /> Inspection Form Included: Q <br /> Comments Included: Q, ( C i, /`C 1~t 1� \ 1 (�UJ 4A-3179 - 1 <br /> Bust ess Re c gn�t Phone Number nspe is Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:* Incorrect: A MFT IE� I �3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />