Laserfiche WebLink
15-14-Waste Tire Su y & Inspection Re ort '*nspection Report Number <br /> .Y 86x, State of California p ■ <br /> California Integrated Waste eManagement Board Survey Form - Page 1 t• 1 V "T Y V V <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection,Details <br /> TPID- �� _ [�[il <br /> Inspection Type (Fill one) <br /> Site Suffix: o _ @ Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local .--- If Referral,choose referral type(Fill one) <br /> Identifier: 07 �- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> r <br /> Business or Facility Name <br /> Inspected B <br /> LL N P y Inspector <br /> Physic I Address <br /> Street � <br /> Inspection Date <br /> ILL '35ZD5l <br /> City State ZIP Code Time In Time Out <br /> Business Rep TitleAM Q AM <br /> m ' m O PM EE 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 /> 0 Active 0'.Passenger 0 Generator 0 Outdoor <br /> Closed ose0 Altered <br /> GPS Latitude O m . d Al O 0 Inactive 0 Truck 0 Hauler 0 Indoor <br /> Longitude - 0 Planned 0 OTR 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 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture — - 0 Shredder 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Genera r, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> C V A HAULING AND MANIFEST REQUIREMEN S <br /> 0 0 'PRC'§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> ._s." 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 <br /> 0. 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB m m <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> _. . ... --... - - <br /> 0 0 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 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 10 1 Other: § <br /> Comments <br /> 64-4 <br /> Inspection Form Included: <br /> Comments Included: 0 ----- - - - - - ?i <br /> `- - <br /> :Business Rep's Si nature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK [Correct:0 Incorrect: ' ; . i4 ,� 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />