Laserfiche WebLink
Waste Tire S eY p Re& Inspection oP Inspection Report Number <br /> s.; p <br /> rr� State CIWMB California I 1 - 114 0 9 7 6 <br /> grated Waste <br /> eManage) 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- Inspection Type (Fill one) <br /> Site Suffix: Ll 8 -11 3 62_ l 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local �^. //a,,� If Referral,choose referral type(Fill one) <br /> Identifier. �Y.1� trl}� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical dre��ss o ax <br /> Inspection Date <br /> 1(lCtI��Gc c%�, C! qSiE v� <br /> Time In Time Out <br /> Business Rep Title 19 AM / 40 AM <br /> 0 PM 0 PM <br /> - <br /> Operational Status Tire Type Business Rote Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> {� ® Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 0 Hauler Q Indoor <br /> 0 Q Inactive IS Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 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 S 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 <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 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 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> In Compliance - No Violations <br /> Q Q Other: § -- <br /> Comments <br /> -- <br /> - <br /> Inspection Form Included: Q <br /> Comments Included: — <br /> ® Business ep's ign ure Phone Number to 's gnature Phone Number <br /> - .. ---- r...._ 62081 <br /> INSTRUCTIONS ON BACK ! Correct:* Incorrect: �/ � X A`. e' 1112131 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co EA © ■ <br />