Laserfiche WebLink
Waste Tire Sum .ay & Inspection Report Inspection Report Number <br /> State of California 11 - 1144038 <br /> CWMB grated asteMana a 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- f � � � � .� r' - � I Inspection Type (Fill one) <br /> Site Suffix: t C.+ l 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalL^�� �� C��i / If Referral,choose referral type(Fill one) <br /> Identifier: X ' V� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l <br /> /Oau s. 6eC,6M /1 �c5 . <br /> � Inspection Date ZJ <br /> L.c:C�� �'� Sa�IC) 66 lJ <br /> Time In Time Out <br /> Business Rep Title r 0 AMO AM <br /> 4D PM OPM <br /> ---- - — - -------------- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) L� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> S Active a Passenger ®Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q End-Use Q Container <br /> Q Planned Q OTR <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 ® 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 1 HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 ; Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q (Required for NOV or EXT) <br /> 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> 0 Q <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 /> V <br /> Inspection Form Included: Q rQ <br /> Comments Included: ® -- - -- - - - - - <br /> Business Rep's Signature Phone Number pct s Ignature Phone Number <br /> INSTRUCTIONS ON BACK ICi orrect:* Incorrect: t w' E x p i 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />