Laserfiche WebLink
Inspection Report Number <br /> A Waste Tire Su&y & Inspection Reporoo <br /> ' State of California <br /> S8r Cgrated Waste <br /> eManag) Survey Form - Page 1 7�7 I 1 - 1127525 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ inspection Details ' <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: E. ? O 0 Routine Q Re-inspection 0 Referral 0 Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: ���� �' 1(l ( �,�:}"} 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A k l� 1ce_ 4 5C r inti' i <br /> Physical Address 5 – i ' <br /> , n , <br /> -�6_1 4i4L r._rc:ft k. _...0 -- <br /> Street � 164 <br /> � � ' <br /> Inspection Date 7 <br /> City _�..r Mate Zip Cade, Time InTime Out <br /> Business Re L P Title � � �� O AM i i � � 0 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 /> It Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude <br /> �— O 0 Closed 0 Altered <br /> ��� � • ���___��...�.L._ � ' Q Hauler Q Indoor <br /> T......._. O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 QTR 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 /> 1 _1 <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> - - - _ ---- 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 / m / 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/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 <br /> 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> -. _ <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ._X A M1 P L E; 1 2 ,13 62081 <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />