Laserfiche WebLink
Waste Tire Su -%y & Inspection Repori� Inspection Report Number <br /> _��_ State of 81California <br /> (New04104) Survey Form - Page 1 I 1 - 1108403 <br /> California Integrated Waste Management Board Y <br /> 'art A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- J Inspection Type (Fill one) <br /> Site Suffix: r I I , I- I J l' I 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local !/ t If Referral,choose referral type(Fill one) <br /> Identifier: �' �o 1. ,1/� ( (.(/ti (� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> r./ I <br /> Physical Address, I - <br /> >t � <br /> t.. Inspection Date <br /> State ZIP Code Time In Time Out <br /> Business Rep TitleL/ © /AM i i . / O AM <br /> 0 PM L PM <br /> I <br /> Operational Status' Tire Type Business Role torage Type <br /> Tire Count (Whole/PT /, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �-( IR) Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude I I , I I 1 . I 0 Closed 0 Altered 0 Hauler 0 Indoo. - <br /> 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container`: <br /> Business Type (Fill alftha apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 'Q) 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 <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 0 In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ; <br /> ( G tic% <br /> ✓/ _� �� / � / r'► + �� <br /> f:��rt.', r'trf � 7`r��n ��{';'�. �'✓' ; , �rN,:1r � � !/,l, , t+ �: <br /> ,Jo V, <br /> � ° u• C 1 <br /> Inspection Form Included: 0 <br /> Comments Included: 0' - - - - <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 1,1 ' 2 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X yi V ! rX!A 04 I_j�� j 3, <br /> i <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />