Laserfiche WebLink
09.2.89049664 <br /> Waste Tire Suftey & Inspection Report Inspection Report Number <br /> State of California - _ <br /> Cgrated asteMana a Survey Form - Page 1 I 1 11412.3 5 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> ffi <br /> Site suffix! I til_ d Ij (�) �I Q Routine 0 Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) . <br /> Identifier: — _Ll`l�l ( n�(� - Q CHP Q CIWMB Q Complaint Q Educational Visit 0 Other <br /> Business or Facility Name w <br /> Inspected By � .� Inspector <br /> Physical Address3T_ j I I I-O-��— I L <br /> I <br /> Wok <br /> L J <br /> Street 10 <br /> Inspection Date i <br /> 0 f\ <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title <br /> `r ®AM i —� -IL4_T__ 0 AM <br /> `� ' 10OPM I I O PM <br /> LwC� -C ���� -- - — - - - Operational Status Tire Type Business Role Storage Type <br /> J----- <br /> Tire Count(Whole/PTE) I 13 0 . (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> • Active O Passenger ® Generator ® Outdoor <br /> r - - <br /> Latitude <br /> -- T O O Closed O A tered <br /> GPS I—J <br /> 0 Hauler Q Indoor <br /> Q Inactive ® Truck <br /> Longitude - I ( I I . i I I 0 Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer O Auto Body O Car Dealer Q Collection O Crumb Rubber <br /> t <br /> Q Service Station O Hauler O Agriculture Q Shredder •Other <br /> Part B - Inspection of-Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF40RGEMENT.ST, ATUS; <br /> ,r. - - - � <br /> V 'A --;HAULING AND MANIFEST REQUIREMENTS Z 1 <br /> Q Notice-Of Violation Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires51 <br /> g ffig <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. ' <br /> § 9 Compllance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements. <br /> O O 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 ', ,(Reguired,f&NOV�&QM,,;� <br /> �x. <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 'alReferied/-'CIWMB Enforcement <br /> 0 Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> o <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators " 3 '.t' <br /> ®�In Compliance No Violations <br /> Q O Other: § <br /> Comments t0\�S �Rv w—"J <br /> -�C T Vim- - - <br /> Inspection Form Included: Q <br /> Comments IncludedQ Bus <br /> e ` J-j/�p <br /> Phone Numberiness Rep's Signature Phone Number Nlnsp�esi Sign t r <br /> INSTRUCTIONS ON BACK Corr ct Incot-rect:'4xi. � E11X A11 P L E -111213] . 62081 <br /> White Copy:CIW Yellow Copy:Operator Pink Copy:LEA ®. <br />