Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> _= Survey Form Page 1 1 2 - 1 0 0 6 6 0 0 <br /> • _;= Stat.of c.91 nia <br /> CM1M6 181(New 841041 <br /> Califomla Integrated Waste Management Board BLUE O EN <br /> Part A-Survey__... � <br /> =4 n <br /> Business Profile Inspection Details 2 VW <br /> TPID- =17- 1 Inspection Type (Fill one) <br /> Site Suffix: 1 3 It ®Routine Q Re-inspection Q Referral Q Observation <br /> H <br /> Local <br /> Identifier: O CHP Q <br /> Referral,choose referral type(Fill one) <br /> _ CIWMB Q Complaint O Educational Visit Q Other <br /> LL!!�', �-/►^, !_/ <br /> Business or Facility Name inspected By Inspector <br /> E:3y� - F 7zz/ <br /> Physics Address <br /> Street Inspection Date <br /> R 5za/1� Time In b Time Ou/t <br /> kty --- - State^27P--r de <br /> AM <br /> Business Rep Title m <br /> O PM L---�---� PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) i 13 p, <br /> ®Active ®Passenger ®Generator Outdoor <br /> 0 O Closed O Altered <br /> GpS Latitude _ Q Hauler indoor <br /> Q Inactive O Truck <br /> Longitude - I 1 O Planned Q OTR End-Use Q Container <br /> Business Type (Fill all that apply) - <br /> ®New Tire Dealer p Auto Repair Q Trucking Fleet Q Government p Retreader Q Dismantler O Tire Derived Fuel <br /> ®Used Tire Dealer Q Auto Body O Car Dealer O Collection Q Crumb Rubber <br /> Q Service Station Q Hauler O Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire-Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A 'HAULING AND MANIFEST REQUIREMENTS O Notice Of Violation Q Extension <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§16459 -Responsible Entities Complying with Manifesting Requirements Date M / m / m <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> (Required for NOV or EXT) <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§16459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®In Compliance - No Violations <br /> O O1 Other: §` /� /'► / - - L <br /> Comments 01 ee- <br /> �C7_r___�i.r-�__�- ��-s - ��—t__—C_�L�S I►^�'�eY i s1—�-�L� <br /> Inspection Included:Q v! <br /> Comments Included:® J;nature Phone Number In s I r1a ure Phone Number <br /> Business kep s g <br /> - - - -- 62081 <br /> INSTRUCTIONS ON BACK Gorrect: Incorrect:�((� E X a M P L. E 1 2 3 © . <br /> ■ White Copy:CIWMB Yellow Copy Operator Pink Copy LEA <br />