Laserfiche WebLink
` Waste Tire Su'ty & Inspection Repor Inspection Report Number <br /> CIWMB 7 7 8 <br /> Californiatate of California ;s a <br /> CL 3" , <br /> R4� ialnt grat dfWaste81 eManagementBoard Survey Form - Page 1 11 0J { y0 <br /> _ -- <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> ��" ���tW.. � ,: '� �f+r��Id l�8�"�^M°"'r��r�'�,i� ✓�r�r7�R��",vi�9�9I��,m m'm`t�7` <br /> TPID- I-- L_ / �. - Inspection Type (Fill one) <br /> Site Suffix: I `= ` dl Routine Q Re-inspection Q Referral Q Observation <br /> Local i If Referral,choose referral type(Fill one) <br /> Identifier: 'i •Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name tk; ' Inspected By Inspector <br /> Physical Addrress <br /> L"T <br /> �,r <br /> Street <br /> Inspection Date <br /> - j <br /> City State ZIP Cade I Time In ELI Time Out <br /> Business Rep Title O AM Q AM <br /> 0 P EF] : FT <br /> _ 0 P <br /> t l Operational Status Tire Type 1j Business Role Storage Type <br /> " (Fill one only) (Fill all that app (Fill all that apply) (Fill all that apply) <br /> Tlre Count(Whole/PTE) r <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> F 1 o Q Closed Q Altered <br /> Latitude <br /> GPS <br /> Q Inactive Q Truck Q Hauler Q Indoor <br /> =17FTT-7 Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Tvil (s=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 I& Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS - <br /> A HAULINGGAMIMANIFEST REQUIREMENTSI � Transport of Tires Q Notice Of Violation Q Extension <br /> Q PR <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 J. l 1 <br /> f �, ,� ( 1c <br /> L/r�). 6 <br /> Inspection Form Included 0 "", t "r �tk � ,���,, ri s�, .i, ••i �,ir. t � ., M s <br /> "w .d ..n .' '. _ � �' �'.r �u/�1��y.� ev/n4�� y' �Fwa `1• , <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> j � - - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � \ k 11 _. I l.- 1 1 , 2 1 i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />