Laserfiche WebLink
'nspection Report Number <br /> _„ Waste Tire Su y & Inspection Report <br /> State B California Il - 1127548 <br /> 04104) <br /> California Int grat d,81 Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � _ � ,Inspection Type (Fill one) <br /> Site Suffix: l ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: +(� V` OCHP O CIWMB Complaint O Educational Visit <br /> Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address t Q.iSG <br /> 95"? Inspection Date <br /> Time In I Time Out <br /> Business Rep ` + Title i 1 ®AM 1 41 ,�AM <br /> C)SurlcbU�� ins' lle� v O PM l l V O PM <br /> Operational Status Tire Type Bess Role I Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 0 Active 0 Passenger 0 Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container . <br /> Business Type (Fill all that apply) <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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS j <br /> V <br /> A HAULING AND MANIFEST REQUIREMENTS <br /> i <br /> -- - - - - -- - &Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 j PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Fla, 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 /> 0 0 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 /> 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 <br /> Inspection Form Included: 01 / <br /> Comments Included: ® — doVCt - --l am - — 0� T�-- <br /> - -- _usiness Rep's-Signature Phone Number I gto Signature Phone Number <br /> _ - --Phone <br /> INSTRUCTIONS ON BACK Corr ncorrect: X (E X AAP 1112 3 <br /> White Copy: .141%N Yellow Copy:Operator Pink Copy:LEA <br />