Laserfiche WebLink
® Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> ,.` State CIWMB California I 1 - 114 0 7 9 9 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> -t A- Survey__.--___ BLUE OR BLACK INK PEN <br /> iness Profile Inspection Details <br /> .,,ID- l f Inspection Type (Fill one) <br /> Site Suffix: ` S 9 �Q "t is jo Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier S(,�,� J —� � 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> 7T e. S; MSI �t C04-'�, -("-I 3 °► - 1 0Physical Address , 0 Es(06 <br /> IWO <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep �J Title i 0 AM0 AM <br /> Wo �� � SG � 1 1 S � PM � � 0 PM <br /> 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 .10 0 Active 0 Passenger 0 Generator 0 Outdo <br /> or <br /> 0 •Closed 0 Altered WA GPS Latitude N 0 Hauler I 0 In <br /> O <br /> 0 Inactive 0 Truck �� <br /> Longitude – 0 End Use Q Container <br /> 0 Planned 0 OTR <br /> Business Type (Fill all that apply) _ <br /> New Tire Dealer 0 Auto Repair f0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> _ Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder ®Other L/UIty. tltty <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> VA HAULING AND MANIFEST REQUIREMENTS !0 Notice Of Violation Q Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> -----. --._- -......._ <br /> O O <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 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 /> 0 0 Other: § <br /> CommentsU, �N(mae -t�'S�- 1 fl <br /> dection Form Included: <br /> Oil <br /> Comments Included: <br /> ® Bu ' ss ep s ature Phone Number Inspec�'sSignatre - Phone Number <br /> INSTRUCTIONS ON BACK orrect.0 Incorrect X J4, l X A MP E 2 L 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />