Laserfiche WebLink
dWasteTireej3y & Inspection ReplatoInspection Report Numbe <br /> State of California <br /> Californialnt grat dWasNew04/04mentBoard Survey Form - Page 1 T 1 <br /> 11 1141261 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: I O <br /> �— l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> Physical Address <br /> Inspection Date l �j <br /> Time In Time Out <br /> Business Rep Title Q AM y0 AM <br /> ' I` ® PM L l ® PM <br /> tvl_C'�-Gu.zic,� ���t�r+r;�f c� ---- -- - - - <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 /> ® Active Q Passenger ® Generator @ Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler i Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR 0 End-Use Q Container <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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other C7,/— <br /> Part <br /> 7,/—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 /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements i Date <br /> Q 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q 0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> i -- <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> I ® In Compliance - No Violations j <br /> 0 0 Other: § <br /> Comments <br /> - <br /> Inspection Form Included: Q Q,p q <br /> Comments Included: ®'—usine--ss R-- (tel= 60-' l Yb _ -- — _ /14 �'G 73 <br /> Bep's tgnature Phone Number In o gnature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct 0 Incorrect i E X - P 1_113 1 <br /> -- - -- <br /> White Copy:-CIWMB Yellow Copy:Operator <br /> Pink <br />