Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Su ey & Inspection Repor <br /> l�tl- State of California <br /> ClW a tdeMana a Survey Form - Page 1 1 8 - 1 0 0 0 5 0 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ! Inspection Type (Fill one) <br /> Site Suffix: j 7y -7 ? g 1 'T1 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> v- <br /> 'r �H � � Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> / Inspected By Inspector <br /> A 6,L"N V,^ '9 <br /> Physical Address <br /> L.-1-- <br /> Inspection Date © 6 / O '7 ( S <br /> Time Out <br /> Business Rep Title Time In 0 AM 0 AM <br /> D PM 0 PM <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 ®Active ® Passenger 40 Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> t) Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O 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 ® 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 ENFORCE. NT STATUS <br /> V. A I HAULING ►ND MANIFEST REQUIREMENTS_ <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q O PRC§42953-Contracts with Registered Waste Tire Haulers. pCompliance Deadline <br /> Q j O PRC§42956-Registration/Decal in Vehicle m <br /> O Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements pate I m J <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB 1 I I <br /> tQ O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Reqt lred for NOV or EXT) <br /> O O 14 CCR§18459.3- Retention of Manifest Forms and Tire Trip Logs for 3 years - T <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred J CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§ 18462- Manifest System Requirements for Tire Dealers or Waste Tire Generators In Cornpllki nce - No Violations <br /> O O Other: § <br /> Comments <br /> Inspection Form lnclydad. Q <br /> Comments included: Q LUL <br /> Business p's Signature Phone Number Ins ctor's Signat Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK CorrectIncorreatt ( V � ljA1 '_I E:: <br /> -----I <br /> �3J <br /> Entered White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> V0 <br />