Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Sui „ey & Inspection Report <br /> State of CaliforniaCIWMB 04104) <br /> T <br /> California Integrated'81 WasteeManagement Board Survey Form - Page 1 I 1 1143704 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- q _ 0 Inspection Type (Fill one) <br /> Site Suffix: $ a ` * Routine Q Re-inspection Q Referral Q Observation <br /> Local / If Referral,choose referral type(Fill one) <br /> Identifier: v Lk,5 n l-UU.nA� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ' - I V f &n <br /> 1533 E _ sr,�y 5�. - --- <br /> 5-}o LyLTD n G A ct5ws Inspection Date <br /> Time In Time Out <br /> Business Rep Title V O AM1 0 AM <br /> i <br /> • PM 1` 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 /> Q Active Q Passenger Q Generator Q Outdoor <br /> D 0 Closed Q Alteredu/A N/A <br /> GPS Latitude NjA Q Hauler Q Indoor <br /> 0 Q Inactive i Q Truck <br /> Longitude - 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 ® 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 c <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® Other <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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 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 NOV or EXT) <br /> Q Q 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 Q Referred/CIWMB Enforcement <br /> I <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> ... ...._. _.. <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • In Compliance - No Violations <br /> Q Q Other: § LC All's <br /> "�I, <br /> Comments K-.1341cla, t1I3fx"Ac' \SCS r S1S(le.t ;On �VV" 01flnux A0 11S (izvvcl afl-4 1612.. <br /> Noo <br /> Inspection <br /> Comme is Included: Q2ness,4/ep's <br /> -3 J 27 , ��'�"y" �d l -100>) b�in1SB Signature Phone Number p or's Signature hone Number <br /> INSTRUCTIONS ON BACK orrect * _]JIncorrect I L � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />