Laserfiche WebLink
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
Inspection Report Number <br /> Waste Tire SL ,Ay & Inspection Repor <br /> State of California <br /> Cal fo <br /> kma Int lWMB grated 81(eow04/04mentBoard Survey Form - Page 1 I 1 10883 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i � � p� /, � � - O � Inspection Type (Fill one) <br /> Site Suffix: O `I' a Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: �n� _ V 0 CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Addre s <br /> L—aa I I <br /> Street <br /> Inspection Date <br /> Stec n J_C 9 5a0�, <br /> City State ZLp Code I Time In Time Out _ <br /> Business Rep Title I � — Q AM Q AM <br /> PM <br /> ®PM <br /> i4s C4- <br /> - -- - Operational Status Tire Type Business Role Storage Type <br /> L/ ,l <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> fl v Active Passenger ® Generator ® Outdoor <br /> O Q Closed O Altered <br /> GPS Latitude - -- - - 0 Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - I 0 Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> (jo New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> ® Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> O Service Station Q Hauler O Agriculture Q Shredder Q Other I I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <br /> O O Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 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 DCT) <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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> 0 0 Other: <br /> Comments <br /> 414�6—k/ w �e_ c &AA e <br /> Wa w Tri rd G75L -cla.h ce <br /> Cc►�e` f al I c�UP �.r S aYt r_� 0 �oM <br /> Inspection Form Included: ® I [� p <br /> �IGo Fl L !-1635 -7�9� 6 <br /> Comments Included: Q — <br /> usiness Rep's Signature Phone Number Inspecto Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Co ec +♦ Incorrect: X M P 1 2 3 <br /> White Col:C Yellow Copy.Operator Pink Copy.LEA <br />