Laserfiche WebLink
Waste Tire S ey & Inspection Report Inspection Report Number <br /> State of California <br /> •Fg�v� <br /> cili gWM6181( ) <br /> fornia Integrated Wasttee MManaganagement Board Survey Form - Page 1 I 1 - 11. 41304 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix 1 Site 0 Re-inspection 0 Referral Observation <br /> Local 1 'if Referral,choose referral type(Fill one) <br /> Identifier: L�� C G�. w_ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> I <br /> Business or Facility Name VI Inspected By Inspector <br /> Physical Address 19 — /'.i i <br /> 7 G#� Til } <br /> �"�`�; ------- <br /> C) <br /> -� <br /> C-5 Inspection Date ! i / 1 / <br /> ! i <br /> e <br /> ;tate ZIP Code Time In Time Out <br /> Business Rep Title ( AM Q AM <br /> IO PM .._ i ..._. _� ® PM <br /> „- Operational Status Tire Type Business Role Storage Type <br /> '' (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> `ire Count (`,Nhole/F'TE) <br /> Q Active 0 Passenger Q Generator Q Outdoor <br /> Latitude lI O Q Closed 0 Altered <br /> GPS Q Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Lon etude s ? Q End-Use ( Container <br /> 9 i C) 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 Q Car Dealer Q Collection Q Crumb Rubber <br /> LO 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 m <br /> QQ 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date W <br /> Q Q 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m m <br /> Q Q 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <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 I 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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> i <br /> Inspection Form included: Q <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature : Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: x , ti (� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />