Laserfiche WebLink
S: Waste Tire' S Ispection RemerY & Ins ection Re n <br /> State of California <br /> p � CIWMB1811st(New Manage Survey Form - Page 1 1 • 6 - 3 0 Q .� � � 2 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> a `' Business Profile Inspection Details <br /> TPID- _ _ Inspection Type (Fill one) <br /> Site Suffix: � f I � � ` { • <br /> ! t• Q Routine O Re-inspection O Referral O Observation <br /> Local r^ If Referral,choose referral type(Fill one) <br /> Identifier: t l 1 ;'�;•C�! a r <br /> .J tr Q CHP O CIWMB Q Complaint Q Educational Visit O Other. <br /> Business or Facility Name Inspected B J <br /> ff _y P Y Inspector <br /> Physical Address <br /> Street <br /> r s f••� - - Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title @ AM <br /> OO AM <br /> 0 P ® 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 /> f f I I �-'� <br /> ® Active Passenger Q Generator 1Z) Outdoor <br /> MO 0 Closed �;Altered <br /> GPS Latitude m • 0 Hauler 0 Indoor <br /> O O Inactive . 0 Truck <br /> Longitude - FTIO Planned 0 OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer O Auto Repair O Trucking.Fleet O Government 0 Retreader Q Dismantler O 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 I <br /> Part B- Inspection of.Waste Tire Dealer, Generator, Hauler and End-Use Facility -ENFORCEMENT STATUS <br /> V A 1 HAULING AND MANIFEST REQUIREMENTS <br />' - - - - Q Notice Of Violation Q Extension <br /> Q 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 .Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date E] � [1:111-1 <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EX7) <br /> _.... . - - - <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ----------- ----------... <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q. 0 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 <br /> In Compliance - No Violations <br /> Q 0 1 Other: § <br /> Comments <br /> �i {11,w+11 Itt (`(- /t V> iI�'1 ,d 1�'- +J ✓541+�f �,� G �U IIL jy.r�l�i- :, t+S..l/`, �,,/t r.r <br /> USP, ! '7' iE 1, rccl. f /�.) ' . i �c� l'r ,•zl!_t/P I, r <br /> :r Q <,c, C � I�FYrl' /�C� �i!'i! �l.L�l• / u� r(J o- <br /> ire S <br /> Inspection Form Included: , <br /> Comments Included: ' <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: O lei P 1 C <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br /> 1� <br />