Laserfiche WebLink
■ Waste Tire : & Inspection Rep spection Report Number <br /> State of California - 1 6 - 10066941_._..-.._._I ■ <br /> 04/04) <br /> California Int grat dCIWI3f81 Was eeManagement Board Survey Form - Page 1 1 <br /> Part A Surve BLUE OR BLACK INK PEN <br /> R E "MT, <br /> :r!' <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 2 ( Q r <br /> 0 Routine Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: / <br /> `--�� ..,.� :� � �� �g s 0 CHP 0 CIWMB Q Complaint 0 Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> P y Inspector <br /> Ph ysical Address <br /> Street kk <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> [1]Business Rep Title /! ® AM O AM <br /> F r r Operational Status I r t y,W �� Business Role Storage Type <br /> (Fill one only) r (Fill all that apply) (Fill all that apply)'. <br /> Active @ Generator Outdgor <br /> „ <br /> 1 a rare�+areXw <br /> GPS Latitude D 0 Closedr �'"sr"�" �i,r <br /> ED -[ I -_I 1 �r r t J w 4r <br /> M r 0 Hauler <br /> O <br /> 0 Inactive <br /> Longitude — 0 Planned <br /> End-Use r �t� ✓ I h <br /> wi <br /> " a»r r , s ,:;'.. i `"�,:�.sy H"✓,t�c�7/yr,.. rw" ar: w ,"X', �; t s Mir' �a ^7u 1 r<" 'a ^'� i,X r *auk: <br /> u<<:WM...r�..,..a:n'.� ,.: =—y' a „tea,, �. w;� ,._�,�t,��rown�� ,�X�.�t.a,.�;�� [a.�S,�tiXa.f,_ ��'�'fb, �w. �*�a�;� r��F'X,�, ata..�i�"� r'�"�•,�XarX'.a:�'""wX,�. ��`"th�Ywari"�i ��iwy,,h ar�y�"! 'r „� <br /> New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ' ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years — <br /> 0 0 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 1 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators '' <br /> �, of In Compliance -� No Violations <br /> 0 0 Other: § <br /> Comments <br /> — --r 1 <br /> ����w f'taiW;�q 6 i � w• ra � r � w <br /> INSTRUCTIONS ON BACK Correct-* Incorrect: I A M --- <br /> f - 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />