Laserfiche WebLink
Waste Tire Susy & Inspection Reportolnspection Report Number <br /> State of CaliforniaCIWMBI 1 - 1088345 <br /> ew 04/04) <br /> California In egrat dt81 Wastte Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> — -- -- _ — <br /> TPID- f ! Inspection Type (Fill one) <br /> Site Suffix: I ' I I I I J 1 3 I + Q Routine Q Re-inspection Q Referral Q Observation <br /> Locali If Referral,choose referral type(Fill one) <br /> Identifier: ` C Qv -1 0 y�y; l• Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address .J \ { �1 I J C f [Lis e <br /> O1 <br /> r'live <br /> Yreet <br /> Inspection Date �) <br /> kCk t�i�� � rJ v " I r <br /> State ZIP Code Time In Time Out <br /> Business Rep Title 0 AM F 0 AM' I QPM 0 P <br /> Operational Status Tire Type Business Role TStorage Type <br /> Tire Count(Whole/PTE) 771(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> _ ctive Q Passenger Q Generator Q Outdoor <br /> O�0(g <br /> 0_ClosQ_d.,_ Q Altered <br /> � m - <br /> GPS Latitude O Hauler Q Indoor <br /> O inactive Q Truck <br /> Longitude — U Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that appy' <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantle Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber } <br /> i <br /> ® Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility EN: RCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> J / _ <br /> Comments 1..n <br /> t l Ctjci A <br /> �Ctf ��� l�Qt1 � t'�fr( C� 1U ('r1ClC �It/ �� �fc-ty1.1 ` � <br /> r,yj ! t, zl i Cr I p Cc ((' l (Zf <br /> - �- -- - <br /> Inspection Form Included <br /> Comments Included: O Business Rep's Signature Phone Number Ins ector's Si na^ <br /> ture Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X �i V ;E XA MjP i LIE, 1 I I L 3� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />