Laserfiche WebLink
0?059Q50�09 <br /> :.! Waste Tire Survey & Inspection. Report Inspection Repo um er ■ <br /> in. <br /> ;r stat°o1 Ca Survey Form - Page 1 �I 2 . 10 13 2 3 3 <br /> C=8191(New 9uo4( <br /> CalHomia Integrated Waste Management Board <br /> Part A•Survey BLUE OR BLACK INK_PEN <br /> Business Profile Inspection Details <br /> TPIDInspection Type (Fill one) <br /> Site St>frx: El , <br /> Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 1 If Referral,choose referral type(Fill one) <br /> Identifier: �_S 0—o_- <br /> CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name �4 Inspected By Inspector <br /> Lo crf-o 7e Ser✓,c e 3 - t TOIF <br /> Physical ress <br /> -- <br /> Street n <br /> !5 Inspection Date b ]2- / O s / (c <br /> City 1 <br /> I IV/r1 y —�otare Z Time In Time Out <br /> 7P Code <br /> Business Rep ��//� Title 'r`� �/' O AM =1 0 AM <br /> �� idr�.� u L_�Vv Y �_ LE LEO PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) �. i y> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 CJ 0 Active ®Passenger 0 Generator ®Outdoor <br /> __T I 11I0 0 Closed 0 Altered <br /> GPS Latitude ( I {( { i 0 Hauler 0 Indoor <br /> _ l <br /> J__i _J L _ __ ._1_--J 0 Inactive 0 Truck <br /> Longitude I I I Q Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 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 I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENTSTATUS _ <br /> V T A j HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> m / m J✓m <br /> 0 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 MOV or DCT) <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 I CIWM8 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 <br /> 0 In Compliance - No Violations <br /> 0 Other. §•' , 'f �/ .}, / `l <br /> Comments o s - % - -- '7fp1A S da* ltD � <br /> �� _ s no :ed• O►- a 'f I G'1, <br /> Tro d✓es W461-'- firespom s �t cnl VIEW l(�cc( 7r✓�s <br /> n 51ye puf-n6sed cry �►c N_i�wf l �-�6 r � e� y ��c <br /> "_rom oW, 6 tre �o 5_ane L5 --Arez vtcrs <br /> Inspection Form Included:0 c <br /> Comments Included: <br /> Business Rep's Signal Phone Number Inspect 's SI re Phone Number <br /> ■ Z�( 1 Z <br /> INSTRUCTIONS ON BACK Correct:* LJ EXAMPLE 3 62081® ■ <br /> White Copy:CtWMB Yellow Copy.Operator Pink Copy.LEA <br />