Laserfiche WebLink
Waste Tire S y & Inspection ReporAp- <br /> State of California a <br /> CalifomiapIntegrated CIWMB f Waw 04104 <br /> ste81 eManagement Board Survey Form - Page 1 I .1 V 1060 1 <br /> Part A- Survey - I. <br /> - BLUE OR BLACKINK PEN <br /> Business Profile Cetus <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: (� / ® p 0 <br /> f�. { ' i Routine Re-inspection Referral Observation <br /> Local `; 1 If Referral,choose referral type(Fill one) <br /> Identifier: ({ j QC"I��f� ut {y� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name J Inspected By Inspector <br /> Physical Address T� / <br /> Street P <br /> Ins ection Date <br /> ( rlC I L. I <br /> City ty State ZIP Code Time In Time Out <br /> Business Rep rJ f r' (/ Title m 0 PM � 0 PM <br /> f f r�! t: ✓ .l!.'t t, 'c' ! t'.. r a t t If <br /> ccr <br /> 1 � Operational Status Tire Type Business Role Storage Type <br /> -jti (Fill one on (Fill all that apply). (Fill all that apply) (Fill all that apply). <br /> i <br /> (0 Active 0 Passenger ® Generator 0 Outdoor <br /> Latitude Closed Altered <br /> GPS 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude — I 0 Planned 0 GTR 0 End-Use 0 Container <br /> j7�N , <br /> Business Type (Fill all that apply) ,,' <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder (6) Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A i HAULING AND MANIFESTREQUIREMENTS <br /> - — ------- -- 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <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 <br /> M / M m <br /> 0 0 1 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 1 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 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 0 In Compliance - No Violations <br /> 0 0 Other: §p <br /> Comments 3, d <br /> l Ut{ ( t/t,i lu't f 1 ' O,t 01e �t �`,i vt <br /> ' w <br /> < ) <br /> d <br /> cW rr c, l a I 1--tri E �� > � r� L4_ t% <br /> Inspection Form Included: 0' <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X Pi (�'C i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA _�.. ® ■ <br />