Laserfiche WebLink
Waste Tire St, . ey & Inspection Repoli , Inspection Report Number ■ <br /> � California <br /> California Integrated Waste Managenage Survey ment Board Form - Page 1 Il - 1127651 <br /> Part A-Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ � ( Inspection Type (Fill one) <br /> Site Suffix: `� 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S�41n�O lU,}n C( � ' 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ ` <br /> Inspected By Inspector <br /> _ j � _ <br /> Physical Address � &0 <br /> %19_7 HOJ4fA ISA, <br /> i S U �p is-33� Inspection Date / ¢ (1 <br /> 1,/1-1F ly}I Time In Time Out <br /> V <br /> Business Rep Title (J O AM r'� /� 0 AM <br /> .L � 0 PM 3 V lJ � PM <br /> 4' f�o�1�, Env_ 4�'b4- <br /> - -----_ -- - - -- -- <br /> - -R <br /> � - - - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' 0 ®Active 0 Passenger 0 Generator 0 Outdoor <br /> � 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> D 0 Inactive lb Truck <br /> Longitude — 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> OService Station O Hauler Agriculture O Shredder ® Other f1y j l VI�(�i`(1�SS m�nu�u�uTd' <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V AHAULING AND MANIFEST REQUIREMENTS <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 / m / 0 <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 ® In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Q(4, -- _ __ � _ _ 15 noW ,.'>1(12, oC ' <br /> -- -- - <br /> e5' .f�(.i�Ak K 4L. ru nnv 0.s`I�r%r n)ll,.�"ef�r� lllMj ,'�a.fe�-6U14L',(A�1C�fn 46J► <br /> i <br /> ,Inspection �' ad 11 <br /> Form Included: i <br /> I <br /> - -- -- -1 �J / Z47 114-31-7- � �47� - - 1 - D_3�7U <br /> - 01,Business Rep's Signature L LF <br /> Phone Number InspecrrsSignature Phone Number <br /> Comments Included: <br /> INSTRUCTIONS ON BACK Correct: Incorrect: �: �/,. h X J ' ( 1 j 12 1 3 I 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator J Pink Co y: ■ <br />