Laserfiche WebLink
Waste Tire Sur . „y & Inspection Report inspection Report Number <br /> State of California <br /> B04104) <br /> I - 1127519 <br /> California Int grat dfWas eeManagement Board Survey Form - Page 1 <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection( � n /^ � - � I Type (Fill one) <br /> Site Suffix: "� 030 ( , - O <br /> 3y Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local51 t If Referral,choose referral type(Fill one) <br /> Identifier: �`n, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> o� <br /> Inspected By Inspector <br /> Physical A�ress <br /> I� c 'S p�e S�� Scr vi c.� 3 �1 - l b I (� <br /> I{ CA <br /> _ J i� Inspection Date � I � ( j� / 0 <br /> � ���U <br /> o���� GA Time In Time Out <br /> Business Rep Title I I AM f� ip AM <br /> fill 1 �bn Q_r 1 O S O PM I V ' S V O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q '40 Active ®Passenger %Generator Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude � 0 Hauler ►Indoor <br /> O 0 Inactive I&Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 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 ® Other DI�ULI -Trq(,� 0.1 T <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- --- - -- -- - - ---- - — 0 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 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FFI / M <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 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 f 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 In Compliance - No Violations <br /> 0 1 0 Other: § <br /> 'JI I D n W45 r Q 0 3 ok e anr� f o 1bt,�a n fJb cG� <br /> Comments 1 1 I I <br /> —+0 <br /> Inspection Form Included: r <br /> p Comments Included: 0 -=L c=am ✓ 0��4 �Wr'sSignat <br /> �0 Business Rep' Signature Phone Number InPhone Number <br /> INSTRUCTIONS ON BACK Corr +, ncorrect. X /P V E p L T 3 62081 <br /> White Copy. IW B Yellow Copy:Operator Pink Copy:LEA <br />