Laserfiche WebLink
Waste Tire Sui vey & Inspection Report Inspection Report Number ■ <br /> State California I 1 - 1127949 <br /> CIWMB 181ornia 104) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> - BLUE OR BLACK INK PEN <br /> PartA--Survey- <br /> Business Profile Inspection Details <br /> TPID- lJ Inspection Type (Fill one) <br /> Site Suffix: ` a ,�� C ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \ / If Referral,choose referral type(Fill one) <br /> Identifier: �►� �C)CL(20�1� CC-uyt Z�� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Z_cf\," 0. C_�, , 0 . 9 _ r - <br /> Physical Address lC1�2 <br /> Inspection Date <br /> CA % f / <br /> Time In l Time Out <br /> Business Rep Title O AM O AM <br /> PM ( is PM <br /> -- - — — Operational Status Tire Type � Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) <br /> Active ® Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O O Inactive ® Truck <br /> Longitude — O Planned Q OTR O End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair Q Trucking Fleet ® 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 /> - <br /> j V A HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 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 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 0 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 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 1 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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Inspection Form Included: Q 2vq-33/-71 7 9 _ <br /> Comments Included: * — , — - — --— � ��- <br /> -- ------------------—------ ----- <br /> Business Rep's Signature Phone Number Ins tor's ig ature Phone Number <br /> -_ 62081 <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X Ap V. A <br /> Copy: <br /> White- - :CIWMM <br /> ■ B Yellow Copy:Operator Pink op A ■ <br />