Laserfiche WebLink
AWaste Tire Sufty & Inspection Report4bnspection Report Number <br /> . State of California <br /> Cgrated 1st(New <br /> Manag ) Survey Form - Page 1 I 1 - 114117 7 <br /> California Integrated Waste Management Board - - - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile inspection Details <br /> TPID- ' j ,� (� �� '� � � 1 1 I Inspection Type (Fill one) <br /> Site Suffix: J Q Routine Q Re-inspection Q Referral Q Observation <br /> Local I �^ If Referral,choose referral type(Fill one) <br /> Identifier: OCL !���(}��� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> r t <br /> _ 1 _ <br /> Physical Address . .._j <br /> L........._... �....__ ....._`....V.._............ <br /> Streei <br /> I <br /> Inspection Date ! / I <br /> I oC <br /> Time In Time Out <br /> ,., Sta7; ZiP :,ade <br /> Business Rep Title O AM ]. AM <br /> L 0 PM OPM <br /> t.. Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole PTE) <br /> i <br /> (Fill one only) (f=ill all that apply)' (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator QOutdccr <br /> O Q Closed Q A6tered <br /> Latitude <br /> GPS i l Q Hauler Q indoor <br /> - Q Inactive Q Truck <br /> Longitude Q Planned 0OTR Q End-use <br /> Q Coi twiner <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q 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 (Z) Other 8�rt(, t t� I (n <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> --- Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> QQ PRC§42956-Registration/Decal in Vehicle _T] <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / [ m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred(CIWMB Enforcement <br /> Q Q 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 Q In Compliance - No Violations <br /> Q Q Other: <br /> Comments <br /> C. <br /> Inspection Form Included: Q <br /> Comments Included; Q <br /> Business;Rep's Signature Phone'Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X 1- \/ t X A tit P; <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />