Laserfiche WebLink
Waste Tire Sul► - ay & Inspection Repoi Inspection Report NumberState ■ <br /> CIWMB <br /> f 81(New <br /> Survey Form - Page 1 I 1 - 1143730 <br /> CIWMB 181(New 04104) Y <br /> California Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile -- Inspection Details <br /> TPID- ^^ Q Q C Inspection Type (Fill one) <br /> Site Suffix: ` d� l p J © ' ® Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local1 n 1 If Referral,choose referral type(Fill one) <br /> Identifier: 5�{1 J 0 Lb( `t�U f1T Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Tracor -��n�o., Q& q� <br /> Physical Ad ss l 0 <br /> 0 ca <br /> Inspection Date � � o <br /> yC Time In Time Out <br /> BusinessRepTitle U O AM 2 Q AM <br /> a PM J O O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 5 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active O Passenger 0 Generator A Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude I Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <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 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q 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 /> Q Notice Of Violation Q Extension <br /> D Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q PRC§42956-Registration/Decal in Vehicle <br /> Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> m / m <br /> Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators e In Compliance - No Violations <br /> Q Other: § 1 L� r1A <br /> iments <br /> O�10takn <br /> �1�10 V i01d,"I�Z�f�S C CJS NCgtS <br /> to Form Included: Q N� <br /> �Business �� 1�4(,ff 31 8 <br /> invents Included: ep's gnature Phone Number Inspec is -Signature hone Number <br /> - - • 62081 <br /> STRUCTIONS ON BACK ; Correct: Incorrect: t /, <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />