Laserfiche WebLink
i° Waste Tire Survey & Inspection Report Inspection.Report Number ■ <br /> =fit. <br /> Staterr Survey Form - Pagel 1 1 9 - 1 0 0 6 5 5 7 1 <br /> C1wMB lel(Naw 04M41Calitomia Integratedated Waneisemugament BoW <br /> Sart A-Survev _ _ BLUE OR BL6gKrINK�PEN <br /> Business Profile Inspection Details <br /> TPID- I I YI r.� l �I - / Inspection a��� ��� <br /> Site Suffix: I 1 I P Type (fill one) <br /> I _ 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local ,�� 1 If Referral,choose referral type(Fill one) <br /> Identifier: 17�Q 0 CHP QCIWMB QCom Complaint <br /> Q Educational Visit Q Other <br /> Business or Facility Name _v <br /> Inspected By Inspector <br /> Physical Address q 13Pr- <br /> ?.3-;13 S' <br /> Srree;her Air `36� I 9 I p 0 9 <br /> �-ll InspectionDate <br /> City State Zip Code Time In Time Out / <br /> Business <br /> ,Reepp / Title O 9 Y O PM 4D AM / D ( g 0 AM <br /> QPM <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 /> •Active Q Passenger Q Generator Q Outdoor <br /> T_ ,D 1Q Closed Q Altered ,f/� <br /> GPS Latitude Q Hauler Q Indoor <br /> 1� D QInactive Q Truck <br /> Longitude Y ; Q Planned Q OTR Q 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Agriculture Q Shredder Q Other 1 <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> 1V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> IQ Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within go days i (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years - <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities `_Y <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q Other: In Compliance - No Violations <br /> § _I <br /> =Comments �aG^�i /[p� dc.� OT` �0�!"< L!/��-+� �F►�y DK ��i�C l-P-tl� 'b�r'rG1 a71� /c4 tc.LeoC �� .��c �ah �u��/w•+�c tL,'�� � �o,.�-Q <br /> Inspection Form Included:Q <br /> Comments Included:Q_, <br /> Bu. Signature Phone Number Inspector's Signature Phone Numbe= <br /> v <br /> ■ INSTRUCTIONS ON BACK j Correct:9 Incorrect:?0', �1I EV ASMI P I L I EI 1 1 12131 62081 <br /> White Copy CIWMB Yellow Copy Operator Pink Copy:LEA ■ <br />