Laserfiche WebLink
08157040086 <br /> cry_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateCalifornia Survey Form - Page 1 1 7 - 1 0 7 9 2 4 6 <br /> CIWMBMB18181 stew 0410 4) <br /> Callfomia Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> f TPID- r ' ,/ - © / Inspection Type (Fill one) <br /> Site Suffix: L �j 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local /f If Referral;choose referral type(Fill one) <br /> Identifier: �� Tp�n :N CcwIV Q CHP Q CIWMB O Complaint O Educational Visit Q Other <br /> Business or Facility Name /TT Inspected By Inspector <br /> [�M - <br /> Physical Address <br /> IStreet — _ —��G/ I <br /> Inspection.Date <br /> City Mate 21P Code Time In Time Out <br /> Business Rep � Title O AMQ AM <br /> O PM m'm O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) r <br /> •Active O Passenger 9 Generator •Outdoor <br /> r I � O Q Closed Q Altered <br /> GPS Latitude I —I I�- I I I Q Hauler Q Indoor <br /> J 0 Inactive 0 Truck <br /> Longitude - I I I I I I O Planned OTR O End-Use Q Container. <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer 0 Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder •Other <br /> — L�i�M <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS — <br /> Q Notice Of Violation O Extension <br /> O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> (� O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ID / m / m <br /> 0 : 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O ' O 14 CCR§18459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 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 Q Referred/CIWMB Enforcement <br /> O 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q 1 Q Other: § <br /> Comments <br /> `3 //�4�w�! �S�d— r" !/S_ph �/�yrlif_P.�—GLS�cP��✓ l -�- ac9 <br /> r'.S V(tuJ/ Ci^a�S— <br /> I <br /> Inspection Form Included:QI CZ�9 <br /> Comments Included:0 - ���'�+ <br /> �BusinessRep's Signafur Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK orre Incorrect:X( 62081 <br /> E XRtMP L E: 4 .2 3 <br /> ■ White C y IW Yellow Copy:Operator Pink Copy:LEA ■ <br />