Laserfiche WebLink
HHS <br /> Waste Tire Sur y & Inspection Report F nspection Report Number ■ <br /> lHH State B California I 1 1140986 <br /> Cgrated Waste <br /> eManag ) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey_ BLUE_OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 2 5- Inspection Type (Fill one) <br /> 3 <br /> Site Suffix: S l - <br /> A Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: t✓V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - _-- -- <br /> Inspected By Inspector <br /> Q (z M © 3 <br /> Physical Address <br /> 100 <�. — <br /> Inspection Date / o <br /> Time In Time Out <br /> Business Rep Title n ® AM _ 0 AM <br /> © 0 PM ` J D O PM <br /> /�rc4l, gos wew �c,v v/ro. Pm-enc#- v- - _ _ — <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ® Active ® Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned ie OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 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 /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q O 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 /> i <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 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> 1q4nA;hina_4— fes?SPeC#T,Zn^.,� CTy,�. N!64 11 S <br /> Inspection Form Included: Q <br /> i � 61� b <br /> Comments Included: ® -- - y <br /> ia CX. <br /> Business Rep's Signature Phone Number n' �pectoes Sig rePhone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � \/ AP 62081 <br /> No While Copy:CIWN113 Yellow Copy:Operator Pink Copy:L <br />