Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> f73 State of California <br /> -� Cgrated Waste Survey Form - Page 1 I 1 - 1088459 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 11 Inspection Type (Fill one) <br /> Site Suffix: L 3 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �� / If Referral,choose referral type(Fill one) <br /> Identifier: w"\ `OVi� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ll <br /> Inspected By Inspector <br /> _f M ClCk_Mq )ell TYvct�t�t Z _ �w <br /> Physical Address �; 1I�QY� lro�aUlr` <br /> P61119 -S der RO - <br /> �J Inspection Date O , O ZY <br /> Time In Time Out <br /> Business Rep Title L 0 O AM O AM <br /> ® PM 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 /> r 10 Active Q Passenger ! Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude - 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V , A HAULING AND MANIFEST REQUIREMENTS <br /> - ------, 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 m <br /> ;Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / <br /> :Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred i 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 G"�7 r,tic <br /> Glu-� <br /> c,)c'.�' rio kmr < - �- na-k.) <br /> lao v►Q o Y Arect,,� o <br /> Inspection Form Included: Q <br /> Comments Included: Q - r /- -�� <br /> le siness Rep's S' tura Phone Number In is ig tune Phone Number <br /> - - - - <br /> // 62081 <br /> INSTRUCTIONS ON BACK Correct Incorrect: X �, V E X A M P L E 1 2 3 <br /> White Co:; C riv..4`j4`'/ '-'Tor Pink Copy:LEA <br />