Laserfiche WebLink
Waste Tire Sui .ay & Inspection Report Inspection Report Number ■ <br /> State B California I 1 - 1143458 <br /> Cgrated Waste <br /> eManage Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ^ � q � Q � - � q Inspection Type (Fill one) <br /> Site Suffix: S 1 I 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: t ' JQ f C()v � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical AddressOvw�l <br /> v <br /> Inspection Date Q O Q Q <br /> c .k n n C �Sa�o U } ll <br /> Time In Time Out <br /> Business Rep Title 0 AM 3 � 5 � PM <br /> l 0 0 PM <br /> OAM <br /> �Ul-1 Fb1e-mq,{� - - ---- - - -- <br /> t`/1 �rt�. F --s � <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 /> f l� o Active Q Passenger 0 Generator Q Outdoor <br /> O Q Closed Q Altered l <br /> GPS Latitude Q Hauler Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned ® OTR Q End-Use 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 U u�� <br /> - - - - - - - -- - ---- F' J <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <br /> 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 i 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 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 /> 010 Other: § I I I �y1^ <br /> Comments �1� �A7� >Je 111 1_t�b, —�� r3 (A diT� �l,�UI I l 11t✓ <br /> Inspection Form Included- 0! <br /> Comments Included: 0i, / w7r % se � Sgu44y <br /> Q <br /> Business Rep's Signature Phone Number Inp <br /> Pftone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink EA ® ■ <br />