Laserfiche WebLink
= , Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Sheollei IN is Survey Form - Page 1 1 9 . 1 0 1 3 0 4 1 <br /> CIWMB <br /> tat(New 0/104) <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- tf�, �`.y t - Inspection Type (Fill one) <br /> Site suffix: l q 5 1 ;,3 1 - O ' •Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � (/) Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Mlc,5on WWI 14hir Mod , TY)Ce 3 _ ! I �26�vu �,t-(z'_ <br /> Physical Address <br /> 37:30 M�un F AVe'=', t <br /> stcktyl f Iv/I� C?5 � Inspection Date C) �i <br /> Time In ` Time Out <br /> Business Rep Title O AM 0 AM <br /> 0 PM 0 PM <br /> L Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 10 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I ° 0 Active Q Passenger ®Generator Q Outdoor <br /> Latitude O Q Closed Q Altered <br /> GPS O Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q 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 <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other <br /> r <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ! NFCNiE-1U[ENf-STATUS''' <br /> V HA11-ING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation 0 Extension <br /> O Q PRC§42951 Waste Tire Hauler Registration and Tran pet of T les <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O Q PRC§42956-Registration/Decal in Vehicle M <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> 00 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 i. (Required for NOV or EXT) <br /> O Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O Q 14 CCR§184602-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred I CIWMB Enforcement <br /> O O 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance No Violations <br /> O O Other: § <br /> Comments R� n p C,T Lc^ %✓1'�S oud e- r Z <br /> i <br /> Q 41 cic '-' {h + c�Crv'rc� irk S\. tpl�i 1�# i S Gt ' �JP BUY yAl'c� <br /> e• k�A� - J �Cll l <br /> I <br /> Inspection Form Included:Q <br /> Comments Includ <br /> �fCP <br /> Bus ness Rap' S , e Phone Num er In is g a ure Phone Number <br /> INSTRU TIONS ON BACK E X AN P L E 2 2 3 62081 <br /> ■ White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 0633304.0084 <br />