Laserfiche WebLink
s-P <br /> Waste Tire Sur & Inspection Reportpection Report Number <br /> QState of California - ■ <br /> : 04104) <br /> 4, <br /> alifornia ICIWMBnt grat d,81 Was eeManagement Board Survey Form - Page 11 11 - 10 8 8 0 2.5 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> - . .fir -% �, „.L=A 9 , Yut:" iry„+i� i; ., w.w, ,. ,.. ..r•%A' i.c*- i �i'� _ <br /> Business-Pr.6file <br /> TPID- Inspection Inspection Type (Fill one) <br /> Q <br /> Site Suffix: i -f ( 1 (o - Q s i Q Routine Q Re-inspection Q Referral > Observation { <br /> LocalCru�� j If Referral,choose referral type(Fill one) <br /> n <br /> Identifier: Soy) To q t Irt <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Pt�ttom_o+II,v'p— <br /> Physical Address <br /> Street �� <br /> Inspection Date <br /> In Time Out <br /> City � Mate 79/�Code Time__-�- .._,._._. �.._._._ ..__._ <br /> Business Rep Title 0 AM1 , 0 AM <br /> O PM O PM <br /> J <br /> ......... _ <br /> - - Operational Status Tire Type Business Role Storage Type <br /> TireG'' jjjj (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> i ® Active Q Passenger Generator Q Outdoor <br /> F_7.__7 1__T_ <br /> T-_ —.--�_--0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> - o Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q 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 Q 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 / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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 O 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 /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments a, I n`1 ° <br /> _Ty-),i, c�-ect�o+n- �s���me,c�: -t-h I s d a�-�-_ -ire �o t I o�In�, t�-Qs <br /> n” : r Z_ w cks+6 sed ..i_,ces . S-kC red O r-s)i-C. Q an H o Ias}On <br /> conSer' e_a to � t=awpor►_Zeck msrazGAicnn \AQ11 ?reSe_0+_ U- <br /> E�1-- FflGi�1 .1. VU� ��Yl P�t. f .:, { ) {f S , �f,.��`ti�•, � t. 5 _ c� "t ..Y� <br /> Inspection Form Included Q <br /> Comments Included. <br /> Business Rep's Signature Phone Number Ins or's Signature ° " Phone Number <br /> ® � �� � 111213 <br /> � I 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: L�,. 1 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />