Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
r <br /> ■ a <br /> Waste Tire Survey & Inspection Repos ` ' Inspection Report Number ■ <br /> CIWMB 81'fornia <br /> (New 04/04) Surve Form - Pa�uye 1 I 1 1140902 <br /> California Integrated Waste Management Board Y J <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspectionspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: li 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local r If Referral,choose referral type(Fill one) <br /> Identifier- � t�t ��� �csvry Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - <br /> Inspected By Inspector <br /> Physical Address ( 1 -At hc�c) f'1'YGtI'i'(bJo <br /> -� Inspection Date <br /> rules GAsTl / <br /> ` Time In Time Out <br /> Business Rep Title / 0 AM 0 AM <br /> "'° Y•Y i1.\ � Cren�rc�l �C-*� ._ � ;� V C4' O PM 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 /> Active it 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 Planned Q OTR ; Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader ® 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 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 i Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 <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 O 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 j <br /> ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q <br /> Comments Included: ® -/-��� ----- --"-'-7- �f�� <br /> Busin�p's Signature Phone Number nsp at a Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X x A P L - T2131 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py:L <br />