Laserfiche WebLink
Waste Tire Spy & Inspection Repo*Inspection Report Number <br /> State of California ■ <br /> 7m%r:5m CIWMB 04104) <br /> R �/y <br /> California Int grat df81 WaseeManagementBoard Survey Form - Page 1 11 - 108 8 0 32 <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile, Inspection Details I <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: Z Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S Ur-, To Q 9 Ll\I-) C 0 V1(,�l <br /> 0 CHP 0 CIWMB O Complaint O Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> esj 0 <br /> Physical Address <br /> F�i <br /> J 1 1 - <br /> _I G 0_7 CafV-Vov) <br /> Street -- <br /> Q <br /> Inspection Date 1 Lo <br /> C Z-I 1 / 0 <br /> ..._....�A�_te 2 q -. <br /> i_ �P <br /> StaZQ <br /> � -Zode Time In Time Out-] : I _7 oPm <br /> Business Rep Title (iJ—]—,0 Am — 0 AM <br /> 0 Pm <br /> -"- Operational Status 1 s ,�i„ , '✓'t Business Role '$torago, 'ype ;�1 <br /> p " (Fill one only) (Fill all that;apply)i (Fill all that apply) (Fill all that apply)! <br /> Tire Count(Whole/PTE) 9 <br /> ®Active 0 Passengor (a Generator i (�Outdoor <br /> --- <br /> Latitude C 0 Closed (�Altered <br /> �PS • O Hauler 0 Indoor <br /> ET_ D 0 Inactive C)TruckNA <br /> Longitude - Planned 0 OTR 1 Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> I <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection 0 Crumb Rubber <br /> 0 Service Station O Hauler O Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ! ENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Extension <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 114 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / M <br /> m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years -�- <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred l CIWMB Enforcement <br /> O O 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 In Compliance - No Violations <br /> O O Other: § <br /> Comments <br /> Rout'r%e %n c,-t 0 _ r o r_ <br /> e. `ihis -Z'e7f 01owlr�c)0 o & <br /> r -A�__k1-Il_:�an -ujo�_►re., <br /> �I T me+n i eSkS turn 2000 t,,n -'o -t-yi►5 CACA-e. h04-e_ k,e n rP_'u1n_r1 �- Prey l o_L4S <br /> Inspection Form Included <br /> Busrness,Re 's`Si Sign , <br /> Comments Included: Oil i <br /> _ - p afure Phone Number ature Y Phone Number <br /> _ _.�_ 0 - T2 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: ' E� ! <br /> eWhite Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />