Laserfiche WebLink
07312040409 <br /> aea- <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> State wMB1California Survey Form - Page 1 I $ - 1 0 1 0 $ 2 <br /> q rated W stew04104) <br /> nage <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one) <br /> ffi <br /> Site Suffix: ®Routine Q Re-inspection Q Referral Q Observation <br /> Local - If Referral,choose referral type(Fill one) <br /> Identifier. `Je _ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected B Inspector <br /> P Y <br /> I �h.e � `1 h� a <br /> D�A L l�- <br /> Physical Address <br /> I [ &-e '? 9a Sf-ai%j( (I <br /> a'-'se I <br /> Street <br /> sh�o to-k I? Inspection Date r <br /> City State ZIP Code Time In Time Out <br /> Business Rrep Title O AM Q AM <br /> —kDYJ � � � ✓ m'FT O PM m 'm �PM <br /> �_ <br /> f Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) r I t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> —__ l_ 1 LVJ 0 Active Q Passenger ®Generator Q Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude m• Q Hauler Q IndooS <br /> O Q Inactive ®Truck /��// ,[� <br /> Longitude - Q Planned Q OTR Q End-Use Q Cont r; <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 J <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other ( <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90.days (Required for NOV or EXTJ <br /> Q Q 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 Q Referred/CIWMB Enforcement <br /> Q 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 ®In CompIlance - No Violations <br /> Q Q Other: § <br /> Comments S �Z `.S CJ�U f Q "(�Q / _ (il�S <br /> ��(,�` ——� —7�'e jev_'I u's .41 d4 � ok_& � uJ fy e ELT/V�u- <br /> Inspection Form Included:O f ^ � <br /> Comments Included: I QNpe-qtr <br /> Bus Rejp' inatr Phone Number ns ctor's Si nature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 62081 <br /> XAMPLE 1 ;Z3 ® S . <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA <br />