Laserfiche WebLink
- 07059050005 ■ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State of Callfomi <br /> CtWMe,S,(New 04/e4) Survey Form - Pale _ 12 - 1 i 317 C <br /> California IntegratN Wosta Management Boar✓ <br /> Part A-Survey _ BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- O ^ Inspection Type (Fill one) <br /> Site Sutfix: Vll Routine <br /> 0 ®Re-inspection 0 Referral 0 Observation <br /> Local ` If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> --J. P Y Inspector <br /> Physical Address o3 (N — 51701f <br /> LJ& V, _ <br /> �a�y9 s a �1 r��raaEo I _ 1 wvt - <br /> — <br /> Street <br /> r' Inspection Date <br /> fty Slate ZIP Code Time In Time Out <br /> Business Rep Title m' 0 AM 0 AM <br /> O M m'm O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I I^ (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r i ' U <br /> r ®Active ®Passenger ®Generator 0 Outdoor <br /> GPS Latitude l I I O 0 Closed 0 Altered <br /> 1_ 0 Hauler 0 Indoor <br /> r —T—=' = — - O 0 Inactive 0 Truck ` <br /> Longitude _ i I 0 Planned 0 OTR 0 End-Use ( 0 Container <br /> Business Type (Fill all that apply) _ — <br /> ti. <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ®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 L l <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle [�P,0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date 3 / 0 J0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments Tq ` 2 fi0 a <br /> JJaw _l�1.5 f�' GTL J�anc�es}S <br /> ;e ,r SrpD�cp.P, IVa W(af, s7�s dr <br /> r a able fy,r' yes bm 1 �e &- sage. <br /> Inspection Form Included:0 M _ <br /> Q 5"77 <br /> Comments Included: IN — � na <br /> Business Rep's Signature Phone Number In tor's nature Phone Number <br /> ■ INSTRUCTIONS ON BACK Correct: incorrect:t&(1) 1 EIRI A M p I LZ 2 3 62081 <br /> While Copy CIWMB Yellow Copy:Operator Pink Copy LEA ® ■ <br />