Laserfiche WebLink
'� tEeaWaste Tire Sury & Inspection Report nspection Report Number <br /> A4 State of California <br /> -- - <br /> CIWMB1811stNew Ma/ge Survey Form - Page 1 0 - 0 3.4 <br /> California Integrated Waste Management Board __ _ _ _, i <br /> Part A- urvey BLUE OR BLACK INK PEN <br /> D � 7 <br /> TPID- / r Inspection Type (Fill one) <br /> I" Site Suffix: <br /> ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: _ ct7 +,%�=1 O O OComplaintQ Q Other <br /> iF CHP CIWMB Educational Visit <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> PhysicalAddress <br /> I <br /> 14;27 <br /> Streetr <br /> 110 <br /> _ Inspection Date J <br /> ( �= 0 I <br /> City - — State ZIP Code Time In Time Out <br /> Business Rep Title Q AM <br /> O PM '_-' '"_L_ 0 PM <br /> Operational Status Tire TypeBusiness Role Storage Type <br /> (Fill one only) (Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> ®Active 0 Passenger ® Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - F-7�� 0 Planned 0OTR End-Use 0Container <br /> Business Type (Fill ail that applY)> , _ <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V ! A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 I�PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> O O 14 CCR§18459.1 a b c -Tire Program ID Number from CIWMB Date <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years -- - -- _ <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred i CIWMB Enforcement <br /> 0 0 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> s �,�Ip Go�plfancc Nor�/Aolatior[s Po�t . <br /> 0 0 Other: § <br /> Comments ) _ <br /> 7 !�..�� ;!.�.��. -•. t!���7��J/ <-<.�^ �.>..'-� <br /> Inspection Form Included: 0 <br /> CoMments Included: 0 _ <br /> § <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � I El 111211_`�': 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />