Laserfiche WebLink
Inspection n Reoort Number <br /> Waste Tire S y & Inspection Repor p -_ p <br /> State of California <br /> M 11 1108406 <br /> California Int grat dteD Waste Board Survey Form ' Page <br /> Business Profile <br /> art Aourley Inspection Details BLUE OR BLACK INK PEN <br /> TPID- + � j � „, Inspection Type (Fill one) <br /> ite Suffix _ @ Routine Re-inspection Referral Observation <br /> Local � n � � If Referral,choose referral type(Fill one) <br /> Identifier: ' 4\�--J U( ' Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I <br /> Business or Facility Name [ _ Inspected By Inspector <br /> Physical Addms f j J <br /> Street Ins ection Date <br /> T1_ 't l.' ...T t �`' r r p (_r-_,-.. I .�1 / ' L 6 / U_ f!— 1 <br /> ---, Time In Time Out <br /> state ZIP Coae <br /> Business Rep —' Title AMr' Q AM <br /> O r ' � �r� 0 P _C -1 F�.11 QPM <br /> f r f — — <br /> " Operational Status Tire Type Business Role Storage Type <br /> �Ttre GC1Un�(�l�I�IO�e� ('a (Fill one only) (Fill all that apply) (Fill all that apply) (Fill alt that apply) <br /> S Active 0 Passenger 0 Generator 0 Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude —� Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR <br /> Q End-Use Q Container <br /> I Business Type (Ril 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 Hauler0 Agriculture Q Shredder Other hQ Service Station r <br /> I-... ..,.-,..._ .. _ _. . ..._., . _..,... _....�_.J <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility (ENFORCEMENT 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 O 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 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOor E2CT) <br /> 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 li Q Referred/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 /> Comments <br /> j " <br /> V !' <br /> i <br /> Inspection Form Included: Q' <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ; 1p p 1A dh�4�P 2_ � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />