Laserfiche WebLink
Waste Tire Su* & Inspection Repo ;inspection Report Number <br /> a <br /> Y p p State of California <br /> CIWMB 181(New <br /> Manage) Survey Form - Page 1 i - 102582" C <br /> _ - <br /> California Integrated Waste Management Board Y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile a�M 011015, <br /> �r 4. <br /> 9?� 1 <br /> TPID- :4 - I\ Inspection Type (Fill one) <br /> Site Suffix: I ,x�. \ ` E Routine Re-inspection Q Q P Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: <br /> _ CHP Q Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name - -- -- <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> 1 Inspection Date <br /> CityState ZIP Code Time In Time Out <br /> `ss Rep Title <br /> � AM __ <br /> Business � i <br /> _- , AM <br /> O PM O PM <br /> Operational Status �r�) i > Business Role <br /> (Fill one only) „ (Fill all that apply) <br /> Q <br /> Active p ,° ) Q Generator r i <br /> GPS Latitude -_ D Q Closed ft <br /> t tt���ft r�qw rr ria Q Hauler <br /> Q Inactive <br /> Longitude ' � <br /> Q PlannedUse ( <br /> +�, <br /> BUSrn'eS��'; .4 x�. 11th'��" ;' f^ ;'� �� l,•r , rY r . �.� sr-- �Aa it , ,,,,; ,�, o-' nt �r, ,� x, <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 /> 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 /> -- - - - — <br /> Q 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 / m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) ' <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire 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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> ti <br /> - <br /> Inspection Form Included: Q -- _ - -- - <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: t� X�A h", a ; <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />