Laserfiche WebLink
- , Waste Tire Sur*y & Inspection Report 6nspection Report Number ■ <br /> State B California . ,� /'� �t /� �f /t A <br /> ➢irnia CIWMB 181(teManag) SurveyForm - Page 1 V 11 _4 fI 4 4 <br /> California Integrated Waste Management Board J ...... <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> j Inspection Details <br /> TPID- I I Inspection Type (Fill one) <br /> Site Suffix: W § Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local � �,�-� If Referral,choose referral type(Fill one) <br /> Identifier: ,> c - i -i' . 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address r <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In (� Time Out m <br /> Business Rep Title I 0 PM . [= <br /> 0 PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> ,,. <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count Whole/ <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude (0 Closed 0 Altered <br /> GPSj-, Hauler indoor <br /> 0 Inactive 0 True <br /> Lon Rude - O <br /> g 0 Planned 0 OTR End Use Container <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 /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 / FU m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <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 /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 1 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 01 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 I' f <br /> Inspection Form Included: 0 <br /> Comments Included: 0 - -_ <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> s 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X '" i ii L <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />