Laserfiche WebLink
WasteeaTire Survey & Inspection Report <br />State of Californi <br />■ eis <br />CIWMB 181(e) Survey Form - Page 1 <br />CaliforniaalifoIntegrated WasttManagement <br />Waste Management Board <br />Part A - Survey <br />_ <br />Business Profile Inspection Details <br />Inspection Report Number <br />1140709 <br />BLUE OR BLACK INK PEN <br />TPID -/ /, /� Inspection Type (Fill one) <br />Site Suffix: I % 7 -/ C 0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one). <br />Identifier: J I t/�Q.� sJ �:u•7.i4� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name rf Inspected By Inspecto <br />Physical Address 3 / / C'1-1cl,Ct -13 <br />�T-5�� F'�fi6f� h G-���Z�� ��"��� r''�'Ct�• <br />S� `4�� <br />Business Rep <br />4� -,e.,q A <br />Tire Count (Whole/PTE) <br />GPS Latitude <br />Longitude — <br />Business Type (Fill all that apply) <br />® New Tire Dealer 111111 Auto Repair <br />U Trucking Fleet <br />�,s ,V)L< <br />Inspection Date <br />Time In / <br />f/ v Q PM <br />Operational Status <br />% (Fill one only) <br />Active <br />O 0 Closed <br />O 0Inactive <br />0 Planned <br />Tire Type <br />(Fill all that apply) <br />* Passenger <br />0 Altered <br />0 Truck <br />0 OTR <br />Government etreader <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 <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />0 <br />0 <br />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 />D / / / C" <br />Time Out <br />*AM <br />0 PM <br />Business Role Storage Type <br />(Fill all that apply) (Fill all that apply) <br />0 Generator 0 Outdoor <br />0 Hauler 10 Indoor <br />0 End -Use 0 Container <br />0 Dismantler 0 Tire Derived Fuel <br />ENFORCEMENT STATUS <br />0 Notice Of Violation 0 Extension <br />Compliance Deadline <br />Date/m/m <br />(Required for NOV or EXT) <br />0 Referred / CIWMB Enforcement <br />(0 In Compliance - No Violations <br />CommentsdZ <br />/�,..� �a�`� /i rc <br />A �• " <br />Awl <br />nspection Form Included: 0 <br />Comments Included: 0����— �6 <br />siness Rep's Signature Phone Number Inspector's Signature_ <br />INSTRUCTIONS ON BACK Correct ® Incorrect XA�, E XIA M h 3 <br />■ White Copy: CIWMB Yellow Copy: Operator Pink Co : L <br />.�Zfl-9 <br />y4'g 9 <br />Phone <br />62081 <br />® ■ <br />