Laserfiche WebLink
Waste Tire Su10y & Inspection Re or Inspection Report Number <br /> State of California Repor <br /> Cgrated Waste <br /> eManage) Survey Form - Page 1 ' ' � Q -- ^ <br /> California Integrated Waste Management Board i ;'� <br /> Part A Survey BLUE OR BLACK INK PE <br /> °rr r i lrt/ 4h" r"I k +' r r1Hr ;t fi t - <br /> .� �..,..,�... kr (rW�a � ,.,�/ t,l ^»; rk /r uj hfim;zr �w N <br /> 'rr ,w�a%��r"� Wa��;,tiru�x r ""c r�z �' IRSp@CtlCrll� t�Sry"��^�k����f�/ � �� <br /> �. o- <br /> TPID- <br /> Site Suffix: �� i — <br /> — I > j j ; - I J Inspection Type (Fill one) <br /> I _l__ 11I ` ' <br /> _ `'' Routine Q Re-inspection Q Referral Q Observation <br /> Local ,..,. I <br /> Identifier: If Referral,choose referral type(Fill one) <br /> ' :� <br /> - 10 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> I <br /> - - - _ <br /> � Inspected By - -- <br /> Inspector <br /> Physical Address <br /> s ° r Inspection Date <br /> City - — tate ZIP Code Time In <br /> Business Rep TitlTime Out <br /> e ` O AM _ AM <br /> O <br /> _ . QPM ACPM <br /> Operational Status 11Business Role <br /> (Fill one only) �µi ! T� � (Fill all that apply) ( I ( f` AMA. t <br /> �i Q Active r r r r r <br /> I � /� ��� Q Generator <br /> p 0ur1 �j <br /> GPS LatltUde i Q Closed <br /> w / t Q Hauler " P 'f <br /> Q Inactive (+ , /"i �r��, �a� � <br /> Longitude ,1 <br /> Irl" / f r.„ ti1',ry ,„,,d � n�l <br /> d ' <br /> ggC Q Planned rr r ?r� <br /> . .�,' T �,;.�r�ll��l�r G�f"� .( r" �"'�j��a�' C'r'rir7�^� r,�r �'�. n s 9-m: ✓� l I'�r n„y�,,�.a" 14�F".,"��r�U� �' I"yx 5�rri���u 7�ya R',���'. <br /> .�",a ...�,. „ I / .._. avNGr._ , urt k � + rlru�,'larr�t,d °�'""'u"� �.'. ^�'" rr ,r�! vq ;r i e ;u rr- .r•rr.-S ' r1 , a/+;. <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government <br /> Q Retreader Q Dismantler Q Tire Derived Fuel I <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS - <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered istered <br /> Waste Tire Haulers. i <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> _Corripliance Deadline <br /> Q I Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q i Q 14 CCR§ 18459.1 (a)(b) (c)-Tire Program ID Number from CIWMB <br /> Q 1 Q 1 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q j 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§"18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> Q Referred/CIWMB Enforcement <br /> Q 1 Q 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 - - - - - - <br /> Q Q Other: § Q in Compliance - No Violations <br /> Comments - - <br /> F'?- =f ��7 �'°f"'�� ,� �'ar r� ddb,l; k � �,;fir �r rr�,r r �",t}"a"r� �Mr�?",'tr�,s` "r.0•'� 2z .taa✓r r � ,r . a <br /> ■ INSTRUCTIONS ON BACK ';Correct: Incorrect: _ I � p <br /> 62081 <br /> -- iii ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />