Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
X321 %0A0082 <br /> ee9: Waste Tire Survey & Inspection Report Inspection Report Number <br /> O��II State of California c <br /> CWMB Waste <br /> eManage) Survey Form - Page 1 Ill 1086956 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile <br /> Inspection Details <br /> TPID- 1 l l� _ I Inspection Type (Fill one) <br /> Site Suffix: it Routine Q Re-inspection Q Referral Q Observation <br /> Local C _ C If Referral,choose referral type(Fill one) <br /> Identifier: � �/� <br /> Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ns Iected B <br /> i-- ?P y Inspector <br /> P- Ck\ `' �5 <br /> Physical dress <br /> 16014 lb �S+ <br /> Street LOA <br /> Inspection Date /lv7 <br /> �s Foy i+rn-� C_ R5Q06LJ <br /> City State LIP Code Time In Time Out <br /> Business Rep Title0 AM h_� 0 AM <br /> —I 'O?-i® PM [77 1 I ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 v ®Active Q Passenger ®Generator Q Outdoor <br /> Latitude <br /> i 10 Q Closed Q Altered <br /> Q Hauler Q indoor <br /> GPS ® TrckQ Inactive <br /> -- - - --- <br /> Longitude - �� i i Q End-Use ® Container <br /> Q Planned ®OTR <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 /> I <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other t <br /> `Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> -------------------------- <br /> WJMHAULING 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 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 EXE <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 1 C-IWMB Enforcement <br /> Q 0 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 /> Inspection Form :nc <br /> ncluded: O <br /> Comments luded: <br /> Hess Rep' Signature, Phone Number Insp to�s Sig t re. Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK MorroT11Incorrect: X f1 JAI P L 1 2 3 <br /> White opy: Yellow Copy:Operator Pink Copy LEA ®. <br />