Laserfiche WebLink
•1tn <br /> Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB grated 1(Now Manage Survey Form - Page 1 1 9 - 1025664 <br /> California Integrated Waste Management Beard <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> •: TPID- 7 r Inspection Type (Fill one) <br /> Site Suffix: 7 7 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: , (A �� 1� Q CHP Q CIWMl3 Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physics Address d <br /> Inspection Date (rj <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> ' QPM () PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 3 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ®Active Q Passenger ® Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 Q Inactive m 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 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 — Q N fjtlf 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. Carth INpCp Deadline <br /> Q Q PRC§42956-Registration/Decal Vehicle <br /> Q Q 14 CCR§ 18459 espnsible Entities <br /> I I m <br /> Complying with Manifesting Requirements Dtttt <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 ° "iiRkl4red fok NOV or EXT) <br /> Q ! Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> I s <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q:If9ippl j IWM8 Enforcement <br /> 3 <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 /> S It $IV ance t No Violations <br /> Qj Q 1Other. § <br /> Comments l C~ l <br /> 4 <br /> U "/cis-,c.�a y� �:�,�_,/��-S �t�•,e �^�- -tz:�r -�'��'�i�:.-. '�-(�^�- f��N� 5... <br /> ;ssRep's <br /> Inspection Form Included: Q /Comments Included: Q �Bust Signature Phone Numbed Inspec s gnature Phone Number <br /> INSTRUCTIONS ON BACK [Correct,* Incorrect ��`:�� vi L7����,�,I P�� ��r4 r L L 2 62of�1 <br /> White Copy:CIWM0 Yellow Copy:Operator Pink Copy:LEA 1 © ■ <br />