Laserfiche WebLink
Waste Tire Sur <br /> gy & Inspection Report Inspection Report Number ■ <br /> State California <br /> CIWMB ISI(New 04/04) Surve Form - Pa e 1 <br /> California Integrated Waste Management Board __. -..,. <br /> Part A- Survey <br /> BLUE OR BLACK INK PEN <br /> } TPID- Inspection Inspection Type (Fill one) <br /> Site Suffix: a � �/ _�� ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local L If Referral,choose referral type(Fill one) <br /> Identifier: � ;,'1 U �� "i lam. 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - - - <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code I Time In Time Out <br /> Business Rep Title -� Q PM AM <br /> ( E_U : C <br /> Q <br /> {'! f �' Vit. Y� 41 l - -1 • Q M QPM <br /> t_ Operational Status t� ��r i'd '' � <br /> , �I p ' �7t� Business Rolei g <br /> u ,,,;I <br /> i (Fill one only) �tl )t % � (Fill all that apply) " d <br /> li-I (6 "y "Active r � � Generator ri <br /> 1 dy"w Y' t,pp 4 <br /> O 0 Closed f <br /> GPS Latitude . I ( " Ot Hauler )u <br /> — - <br /> L <br /> - � 0 Inactive ." ff� f`���,ti�" <br /> Longitude - I 0 Planned Q End-Use <br /> II d <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> Service Station Hauler <br /> 0 0 0 Agriculture 0 Shredder ® Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'I HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 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 IE / m / Ell <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 <br /> 0 0 Other: § 0 In Compliance - No Violations <br /> Comments <br /> ;1 f td✓�" . Ci is {- cr ct..r'<<'( f ,r�'� ; r <br /> %✓'ill. Foc: "f f 1 <br /> (ttvtC{_i.r1 �00�_ /P,` kl(ZlG` ! Jt] 11.Yb17/;( f A 00 " O( �� �. <br /> )f 1 <br /> Inspection Form Included. 0` - - — <br /> Comments Included: 0 ` <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X I X,A 14 � <br /> 62081 <br /> ■ ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> T <br />