Laserfiche WebLink
Waste Tire Su. iey & Inspection Repos 4. Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 4 61 <br /> grated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- 1 _ r-� - /^ Inspection Type (Fill one) <br /> Site Suffix: l�J ( (9 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S(,LCI � ul^ CbU,4Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> M ILr\ al� Sd Cons�suc���n 3 - l <br /> Physical Address &1 1 Es <br /> (apo\ S_ C- 1 Dof&Ldo SA_ <br /> (f,mP 31 Inspection Date I„ 1 /� <br /> VJ 1 CJ <br /> Time In Time Out <br /> Business Rep A l Title 1 M O AM O AM <br /> mt,ki1G� IAi` c naA0 UL[a 1 1qq 1 O PM �. ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> I <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I'Active Q Passenger 0 Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS Q Hauler � Indoor <br /> D Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 /> j V 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 1 Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q ! Q .PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> 0Z 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 EX7) <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q 1 Other: § <br /> Comments �r,t-I j C. + fl •f ll'itIv4L, (1 <br /> Inspection Form Included: Q! (av--L) + J�( 1 f ^�6 <br /> Comments Included: ®, c�� "tfteict d tJ -I��`�1 / 0 <br /> Business Reps Signature Phone Number &gyp Ins ec p is Signa g re Phone Number <br /> � -- --- ----- ---- — � 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect , �i �/' E X. A E 1 ` 3 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co :L ® ■ <br />