Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Irr $tete of Caldomia <br /> CIWM81a1 INS. <br /> 0") Survey Form - Page 1 1 9 - 1 0 1 3 0 0 <br /> Califomia Integrated Waste Manag*M*rd Board <br /> Part A-Survey BLUE OR RI ACK, INK EN. <br /> Business Profile Inspection Details — �.63Q-JQLV4 <br /> TPID- � � o ] Inspection Type (Fill one) <br /> Site Suffix: d / ®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 /> I f C Tru ck-�n� Pj�] - I o ( �a� <br /> Physical Address C1 L <br /> dYop 3. <br /> Street <br /> n Inspection Date <br /> , tl`ji)hy-0li�fU l/lel Time In Time Out <br /> City tale lP Code <br /> Business Rep Title [=:= <br /> LLI <br /> �RM �AM <br /> � ) m 0 PM 0 PM <br /> �J_e /_�Dia—__ �ow�e� - Operational Status Tire Type Buslness.Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> I Tire Count(Whole/PTE) 1 <br /> I �Active ®Passenger ®Generator ®Outdoor <br /> j O Q Closed Q Altered <br /> GPS Latitude I I 1 Q Hauler Q Indoor <br /> r O Q Inactive ®Truck <br /> Longitude ! v l Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ®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 Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / <br /> Q Q 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred 1 CIWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ®in Compliance - No Violations <br /> Q Q Other: § <br /> Comments �OWi t ltK ('►��i��� 1 r r t i s 66f4P To i'D blT tq Wa4 n OfEd: 5 � <br /> ac, �j_trif5 ti ��- ate✓ �►'ae�S,Tres Cw� a�nn�d ems. We Ow <br /> V�Jct�_'r¢ _ _ s�red act ea5� F.�te2. 1.-a^St_o�3�,S� lhatntFes fi �ra� <br /> - �'15�4 �t.-1?o�, ,�tai-�s For 1� � �•- <br /> -V <br /> Inspection Form Included: �, 3� - <br /> Comments Included: 1!f{/b <br /> s n s s Signat a Phone Number Ins_ or'i$g n ture Phone Number <br /> INSTRUCTIONS ON A ' Correct: Incorrect: t IO� E X A M P L E 1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />