Laserfiche WebLink
rrl. <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California - <br /> CM1VA18t811NewM7t14) Survey Form - Page 1 1 2 10 0 5 5 0 , <br /> Califomia Integrated Waste Management Board <br /> Part A•Survey BLUE_QR BLACK INK PEN <br /> rld—entifier. <br /> Inspection Details Jn 6 7)it C(1 f1 f1 r1 _ <br /> [��j <br /> / Inspection Type (Fill one) u I r�tU�l!L <br /> 7 l ] Routine Q Re-inspection Q Referral Q Observation <br /> If Referral,choose referral type(Fill one) <br /> Fs�� �/� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Narrte Inspected By Inspector <br /> t_ .1 --yot _�.z, r GL <br /> Physical Address <br /> Street <br /> �7 H inspection Date <br /> City Statex ZIP Code Time In Time Out <br /> Business Rep Title ©t � � y 7 �PM / O � '� � �PM <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 /> f Active Q Passenger 0 Generator 0 Outdoor <br /> �--- r I 10 Q Closed Q Altered <br /> GPS Latitude 1 Q Hauler 49 Indoor <br /> " Jio Q Inactive Q Truck <br /> Longitude - Q Planned OTR <br /> Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0—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 Q Other <br /> Part B•Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VI 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 /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m I 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 (RequifBd for NOV a FXV <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)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 I* In Compliance - No Violations <br /> Q Q Other- §` - - <br /> s�-tl (� <br /> Comments �u�rG�� _ rQ� // ��iJ �y�77��-��✓ � Lam- aPtf- — <br /> �✓/�- � /�� � ,.,[qct-i'O r1 /Gu.cs,� ��_ /� <br /> X1 <br /> i n <br /> Inspection Form Included:Q � <br /> Comments Included: ( - 5 <br /> mess ep's <br /> — — — —f Signature Phone Number Inspectors Signature Phone Nu- <br /> mber <br /> correct: 62081 <br /> INSTRUCTIONS O 8ACK orrect:. I � V E X�T <br /> © ■ <br /> ■ White Copy.CIWMB Yellow Copy.Operator Pink Copy:LEA <br />