Laserfiche WebLink
i <br /> iS Waste Tire Su_ . ey cit 16spection Reporr Inspection Report Number ■ <br /> State CIWMB California 11 - 112 7 9 3 5 <br /> California Ine grat d Waste 181 eManagement Board Survey Form w 04/04) - Page 1 <br /> Part A-Survey_- -_ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- , �, 1 � � � (� � _ O � Inspection Type (Fill one) <br /> Site Suffix: Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Localc (__ix If Referral,choose referral type(Fill one) <br /> Identifier: Jekv\ JOelxxl n lA 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> L vA Lp-\ �3 _T c\A,&U\Ot 3 <br /> Physical Address <br /> �A Inspection Date <br /> 1 17 Time In Time Out <br /> Business Rep Title1 ®AM 1 0 AM <br /> 1 1 O PM l I 0 PM <br /> — - -- ----— --- - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ( 0 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active S Passenger 40 Generator Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude o Hauler Indoor <br /> O o Inactive 0 Truck <br /> Longitude — o Planned 0 OTR o End-Use 0 Container <br /> — --- --- . ...-- -- - <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler o Tire Derived Fuel <br /> o Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> o 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires o Notice Of Violation Q Extension <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 o PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> o I o 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> o & 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 1 o Other: § L <br /> Comments ; vQ&4c_ +s t i 0 _'� 410 �1V <br /> p2,� �s77 � )� e QA4 <br /> :Inspection Form Included o ' J <br /> )PLhio�n'eComments Included. Business Rep's Signature Phone Number Inspe is Signature� Number <br /> INSTRUCTIONS ON BACK i Correct: Incorrect: XTl. �^ �� 62os1 <br /> --- � '__1 E X A J►ll P L S 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop L ® ■ <br />