Laserfiche WebLink
Waste Tire Survey & Inspection Report "Inspection Report Number ■ <br /> State of California <br /> ClWfvlB <br /> I 1 - 1143498 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- (('�� Inspection Type (Fill one) <br /> Site Suffix: ' ' p� - �J ) Routine O Re-inspection O Referral O Observation <br /> Local t r If Referral,choose referral type(Fill one) <br /> Identifier: S(�(� J �a j1 \b1A ;O CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Busyness or Facility Name r Inspected By Inspector <br /> res�u'S - b (� <br /> Physical Aress 5 1 1 &n �SC�1�T1L <br /> Q <br /> ds CGLV U,(1 �, � �V c _ IJ 11„►�� <br /> t � h Inspection Date <br /> C �53b3 d <br /> A 0 l V <br /> Time In Time Out <br /> Business Rep Title0 AM 0 •AM <br /> � ' ' S OPM � 1 _SV QPM <br /> _f Du �DYI' c,l�l�l}h b(�ra�►o,s � oicc- L ---- - - -- - - - <br /> --J- - - -- - --` - - d Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ®Active Q Passenger 0 Generator O Outdoor <br /> Latitude O Q Closed Q Altered ��� <br /> GPS Q Hauler Q Ind-o�Sr� <br /> O Q Inactive Q Truck � <br /> Longitude - Q Planned OTR 0 End-Use Q Container <br /> Business Type (Fill all that apply) &"6A6 <br /> Q New Tire Dealer Q Auto Repair O Trucking Fleet O 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 l P <br /> O Service Station Q Hauler Q Agriculture Q Shredder ® Other pjS�Tt U �UJ� `��er <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 Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q it 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 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 O Other: § <br /> Comments t x <br /> ---- 0 0 � Ct4C _ S t__-]n5c i on__�_'rk_)f mcI, M 11 G fl ----- <br /> rr,, C 1d <br /> Inspection Form Included: 1� Q (J(p s7p <br /> Comments Included: ut dU 1 -11o0's / o <br /> Business Rkp's Signatud Phone Number Inspe t �ignature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �/ ; , <br /> White - — - - op - --- .-. <br /> ■ Copy:CIWMB Yellow Copy:Operator Pink C y: <br />