Laserfiche WebLink
cuo_ <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Yr6 <br /> Stato of California <br /> califamla In GrW d181(Ne.w 0410Management Board Survey Form - Page 1 13 - 1 4 7 9 1 15 <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- i 3 n 1 ,T - OInspection Type(Fill one)Site Suffix: / J I I ®Routine Q Re-inspection Q Referral Q Observation <br /> Local <br /> Identifier: If Referral,choose referral type(Fill one) <br /> `✓ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _ Inspected By Inspector <br /> IIfo hof Li lu Frei, kk A M � � <br /> Physical Address � (� / - Ft_Fc1) _i o ? Fase. <br /> I I '? 1 ? ,Scz vi�u i n i Lh � — <br /> Street _-y / ® / <br /> S,V�__�__ rl � 5j�2,,05 I Inspection Date <br /> 1 Time In Time Out v <br /> City State ZIP Code <br /> Business AM 0 AM <br /> � La*, o, :F1 <br /> m.m O PM m 1 O PM <br /> -- -- ---— ---_J L� Operational Status Tire Type Business Role Storage Type <br /> j <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � i �� I I <br /> Q Active Q Passenger Q Generator Q Outdoor. <br /> GPS I fI II j I f }o Q Closed Q Altered <br /> Latitude ' L I A —�� Q Hauler Q Indoor <br /> PF IIII O •Inactive Q Truck <br /> Longitude I ( Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> I <br /> Q 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 I I <br /> Part B-Inspection of Waste Tire-Dealer,Generator,.Hauler and End-Use Facility ENFORCEMENT_S_T_A_T_US_ _ <br /> V q I 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 / m <br /> Q Q .14 CCR§18459.1-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§16459.2.1-Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q <br /> 14 CCR§18459.3-Retention of Comprehensive 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 Compliance - No Violations <br /> Q Q Other: §, c/1n yI ,� ,j,,-�, / <br /> Comments _Rmdru n yLd'Irs��jjg?j �S Ao_ e• V�� /lJ es �✓{ce btd A✓Ayl`l <br /> Pl&f T{r�, i P-MCIV Ll C_ua.r�ities less -H . tPuh ca+, o- 4i4 fe <br /> _ 1 u .S f Or2G� UD✓I SZ4le- For 17.c.774ce' !. e a NO /11GAire'St �+'• <br /> �2S <br /> avaJabee mkie r.�e"ed Q ls. <br /> 7- <br /> Inspection Form Included:Q <br /> Comments Included: <br /> siness Re s Signat a Phone Number Inspector's tgnature Phone Number <br /> INSTRUCTIONS ON BACK I Correct:* Incorrect:�0 g E X A M P l E l 2 � 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Copy.LEA <br />