Laserfiche WebLink
Waste Tire ftey & Inspection Rep" Inspection Report Number ■ <br /> StatCIWMB California I 1 112 7 712 <br /> grated 1(New04/04) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _.... --_- - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � � � � � j� _ � � Inspection Type (Fill one) <br /> Site Suffix: o * Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �(,�(1�Oa Win O CHP O CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name 1 <br /> Inspected By Inspector <br /> Cc b%ak C�nc�s�e5' ��� _ d n <br /> Physical Address 3 ' J E6 <br /> J�-��WWWW -- <br /> /� CA Q533,7 Inspection Date ® ``/ <br /> Y <br /> Time In Time Out <br /> Business Rep Title Q AMQ AM <br /> 3 5 PM 5 ® PM <br /> yQC%'T(\ ?0C'0 - <br /> - ---- - -- ---- Operational Status Tire Type Business Role Storage Type <br /> L r <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �h.J <br /> ' Active 110 Passenger Generator Q Outdoor <br /> 0 Q Closed 0 Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude v Q Planned Q OTR End-Use ® Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder O Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> _- ----- -- <br /> V A i HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> 0 O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m <br /> 0 O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> 0 O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § 11 r1 <br /> Comments 0T� ;^ _ n -{- , .{-� .�C7�dW 1 U <br /> k0_\)vD o�s o< arv—us of_ concgin, r Y S/� i-i ems- <br /> NN th,: 1. fF ' ; 5 Ga_�11�� d P -ks as pyil� t kts <br /> Inspection Form Included: O - <br /> --- — G'h �Z ll - �.&gnatt.- ( g Q-3►-78 <br /> I Comments Included: Q -- - -Business Rep's Signature Phone Number Inspre - - Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � X A 1 2 3 <br /> 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py: ■ <br />