Laserfiche WebLink
12 _ Waste Tire Sueey & Inspection Reporr, Inspection Report Number <br /> CIWMI3I1 - 108803.6 <br /> State of California <br /> 04/04) <br /> California Int gratedf81 Was teManagement Board Survey Form - Page .1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ) I g Iv I QRoutine B Re-inspection Q Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: vel-�ovl Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical /�dd�ess 3 l Q l L <br /> Street <br /> L <br /> Inspection Date <br /> Cit O State ZIP Code Time In Time Out <br /> Business Rep Title �C2 O AM O AM <br /> 0 PM ; i ® PM <br /> V.Y1C6 ( Operational Status I Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> (Fill one only). (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t � / f .� �, O <br /> ® Active 0 Passenger ® Generator 40 Outdoor <br /> Latitude D Q Closed Q Altered <br /> CIPS • I Q Hauler Q Indoor <br /> —,0 Inactive Q Truck <br /> Longitude - , 'I I Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ® 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 L <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility IIIIENEORVEMENT STATUS <br /> V A31HAULING AND MANIFEST REQUIREMENTS <br /> e 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 <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 FXf) <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 Referretl/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 i Other: § <br /> Comments <br /> Inspection Form Included:0 Q <br /> Comments Included: - t' \� ��-7 <br /> Busines Reps Signature Phone Number Ins to s St at re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Cor eet: Incorrect: FEN A I r P fL 1 2 3 <br /> White Copy: IWM Yellow Copy:Operator Pink Copy:LFA ® . <br />