Laserfiche WebLink
-:E;. <br /> Waste Tire SuAry & Inspection Reportb pection Report Number <br /> ®Opp State of California - . <br /> Cgrated 1(New <br /> Manage) Survey Form Page 1 1 3 1 0 1 3 7 1 3 <br /> California Integrated Waste Management Board <br /> Sart A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- MC r Inspection Type (Fill one) <br /> Site Suffix: I } t� I (j I , �_.) I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local UA✓1 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: t r0 CHP Q CIWMB Q Complaint 0 Educational Visit 0 Other <br /> f � iJL <br /> Business or Facility Name Inspected By Inspector <br /> LA c <br /> Physical Address J (� <br /> Street <br /> I� Inspection Date <br /> city , State ZIP Code Time In Time Out ' <br /> Business Rep Title SPM / I ? , I `)I 0I 0 AM <br /> Q PM <br /> Operational Status Tire Type Business Role torage Type <br /> _I (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> ONE0977FI 11 ®Active 0 Passenge ® Generator 0 Outdoor <br /> GPS I .I f I I O Q Closed 0 Altered O O <br /> Latitude I Hauler Indoo <br /> V <br /> O Inactive Q Truck <br /> Longitude — I I I , I I I I O Planned OTR O End-Use to Container <br /> t <br /> Business Type ' hat apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station 0 Hauler 0 Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENTSTATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS — Notice Of Violation Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle ..� <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements bate <br /> M / M / m <br /> O Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators O In Compliance - No Violations <br /> O O Other: § <br /> 1 ti <br /> Comments {,Q lt� �i, , _. , c �, _; In( J c}��J(AJt' <br /> J <br /> 1A C �Y i r I _ l f e � �I, <br /> i ' r ( �,.I Ti/L Tr.t ✓r: r F ✓149VUPC>{ . �n ✓Ui�.'.t <br /> af) <br /> Inspection Form Included: <br /> Comments Included <br /> i Business Rep's Signature Phone Number Inspector's II I I 62081 Phone Numb 'j <br /> ne <br /> -_ .-– -- - - /� � <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: I A I � L.I I I i P <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />