Laserfiche WebLink
Waste Tire Wey & Inspection RepAOInspection Report Number <br />State of California ■ <br />CIWCalifornia Int grat dfWas W81 aw 04/04)ste TManagement Board Survey Form -Page 1 i — 1127464 <br />Part ASurvey_ BLUE OR BLACK INK PEN <br />Business Profile i Inspection Details <br />TPID - + O © _ /^ I Inspection Type (Fill one) <br />Site Suffix: 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local` If Referral, choose referral type (Fill one) <br />Identifier: J G`A ,kU, n Cc\A,0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Physical A ress 1 D i & ESC (}art'. <br />��s U� GPe g533D Inspection Date <br />Time In Time Out <br />Business Rep Title O AM <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />-- — — - Operational Status Tire Type <br />(Fill one only) (Fill all that apply) <br />40 Active lO Passenger <br />. C 0 Closed 0 Altered <br />O 0 Inactive to Truck <br />0 Planned 0 OTR <br />0 New Tire Dealer 0 Auto Repair a Trucking Fleet U Government U Retreader <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 <br />V Ai HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />i PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />0 <br />0 <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />0 <br />0 <br />PRC § 42956 - Registration/Decal in Vehicle <br />0 <br />0 <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />0 <br />0 <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />0 <br />0 <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />0 <br />0 <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />0 <br />0 <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />0 <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />0 <br />0 <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />0 <br />Other: § <br />Comments ►� _ , .1\_ _ \ _ _ .._ U n- _l._ r,,.,.. _l <br />aim <br />1 <br />SO AM <br />0 - 0 P <br />Business RoleStorage Type <br />(Fill all that apply) (Fill all that apply) <br />4D Generator 0 Outdoor <br />0 Hauler <br />0 End -Use <br />0 Indoor <br />0 Container <br />Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date <br />M/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />Inspection Form Included: Ui <br />Comments Included: 0 - �.,—p-',Sigrature <br />- - 1_nq-31?1-00r6 <br />Business Phone Number Inspe or's Signature Phone Number <br />INSTRUCTIONS ON BACK Correct:* Incorrect E A P ! 1 2 3 62081 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Co : LE ® ■ <br />