Laserfiche WebLink
j � Waste Tire SL. .,ay & Inspection Repor. Inspection Report Number ■ <br /> State CIWMB California I 1 ew 04104) - 114 3 614 <br /> California Integrat d Was181 te Management Board Survey Form - Page 1 <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 `n —� If Referral,choose referral type(Fill one) <br /> Identifier: �a M t �L'Ya('h C�JC 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name " Inspected By Inspector <br /> f <br /> 1 �o Azim <br /> Physical Ad ress <br /> J.._ Inspection Date <br /> Q5ZI.� <br /> Time In Time Out <br /> Business Rep Title 2 n O AM / , 0 AM <br /> -- r a PM 11110 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) O (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger • Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer •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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 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 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / MICI / <br /> 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB [:m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 0 In Compliance - No Violations <br /> O I O 1 Other: § <br /> Comments �J <br /> 632 <br /> ;Inspection Form Included: <br /> Comments Included: -- - - �'��> 3- 0T 6%0f('Yb U -�,z 7J <br /> Business Rep's Ig ature Phone Number In to s ignature Phone Number <br /> - - - <br /> INSTRUCTIONS ON BACK � C recta Incorrect: I\� i ) ?C ,IVh P L r 62081 <br /> ■ White Co :Cl Yellow Copy:Operator Pink Copy:LEA ® ■ <br />