Laserfiche WebLink
Waste Tire Su. - ey & Inspection Report inspection Report Number <br /> State California Survey Form - Page 1 I 1 - 1143465 <br /> CIWMBB 181(New nage) Board Y <br /> California Integrated Waste Management <br /> Part A- Survey_.- --- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ' (7 - /a 1 Inspection Type (Fill one) <br /> Site Suffix: xu lJ ) 16 Routine Q Re-inspection Q Referral Q Observation <br /> Local eIf Referral,choose referral type(Fill one) <br /> Identifier: n J CL "kI n c(MAAAQ CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or FacilityName <br /> Inspected By Inspector <br /> S1rn �nC'� <br /> Physical Address 3 9 - <br /> 10b0 <br /> s . Aiuolk <br /> Inspection Date 7 0 <br /> S or" C A q5 <br /> Time In Time Out <br /> Business Rep C Title 'l O AM O AM <br /> �fM CkC � J�1. -- - v QPM 3 QPM <br /> - - - -- - - -� - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) y 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ' "� I*Active Q Passenger 40 Generator Q Outdoor <br /> O <br /> Q Closed Q Altered � <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive 0 Truck <br /> Longitude- - - 1 Q Planned j ® OTR Q End-Use Q Container <br /> — - --- - --- — - <br /> Business Type (Fill all that apply) F01641 <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 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A HAULING AND MANIFEST REQUIREMENTS j <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date / / m <br /> Q 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EX7) <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 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 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> w�- u�r�� o��l'. - ---- - - --- - - --- <br /> ,Inspection Form Included:Comments Included: Q " - <br /> •I �jness Rep's Signature Phone Number Inspec is Signature Phone Number <br /> - -- _ _ <br /> INSTRUCTIONS ON BACK Correct:9 Incorrect: X , r � ( ! � 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br />