Laserfiche WebLink
Waste Tire Sui .,;y & Inspection Report inspection Report Number ■ <br /> p=a State of CaliforniaCIWMB 04/04) <br /> I JL 1144000 <br /> California Int grat dt81 WaseeManagementBoard Survey Form - Page 1 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I 7 � � � O � Inspection Type (Fill one) <br /> Site Suffix: "� ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �- ) If Referral,choose referral type(Fill one) <br /> Identifier: S�� Ju,I n Ca1.>t,n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> anJ T alt 4411 - ) 1 <br /> Physical Address 0 <br /> Inspection Date 5 / I 3 / f V <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM • -- 0 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 Active Q Passenger Q Generator Q Outdoor <br /> - -- -- O ®Closed Q Altered 04 fVA <br /> GPS Latitude NA Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer J9 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> A HAULING AND MANIFEST REQUIREMENTS <br /> V 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 <br /> m / m <br /> 0 - 0 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/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q j 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments Q-0-wk-1 n i0A — (� <br /> FC,6'l1'6 1A�s cl��, �� 64 a rsl„P� <br /> Inspection Form Included: Q <br /> Comments Included: -- <br /> Qi Busi ss ep's Signature Phone Number _Inspe is Signature Phone Number <br /> - . — i _3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect AA m P j . <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />