Laserfiche WebLink
r3'3�OQ�(�J�9 <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stat.of Ca libmla <br /> awMBtat(NewOM04) Survey Form Page 1 1 8 - 1 0 7 3 3 4 0 <br /> Calilomia Integrated Waste Management Board <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Q _ [a] Inspection Type (Fill one) <br /> ffi <br /> Site Sux: ®Routine Q Re-inspection O Referral Q Observation . <br /> Local ��'��'� If Referral,choose referral type(Fill one) <br /> Identifier: TO 0- 7� { / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Na e. l <br /> L—' S S /� 5�� I Inspected By Inspector <br /> cr'Physical Address <br /> Street / / p n <br /> Stab C4 �J5�Q� Inspection Date g� (J / <br /> City State ZIP Code Time In 7 Time Out <br /> Business Rep Title 0 AM 0 AM <br /> m'm O PM m'm O PM <br /> ��•�/\_ ,-u 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 /> I r I r to Active I@ Passenger ®Generator ®Outdoor <br /> f I O Q Closed Q Altered <br /> GPS Latitude W Q Hauler Q Indoor <br /> D Q Inactive ®Truck <br /> Longitude - Q Planned (11P 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 O Dismantler Q Tire Derived Fuel' <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber 1L 1^^ �` ' <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other l�t/rw/r TV C t <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENF.0. EMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q 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 m 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 F,CI) <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/C-IWMB Enforcement <br /> Q Q 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q ® 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators (�In C-ompliance MN-61 Violations <br /> Q Q Other: §, <br /> Comments �rms,_ m WO sen_ <br /> U1��S�L DIS <br /> Waw review . TPIa* notMfed ok- on o,V forms '4/e.-ma,ASesf s <br /> '✓ All <br /> TPi noi- lp�( an all vena ncF�s�- �`priM s. k�v� -tirPAS_ <br /> ✓ oVs c�_ n1 �,�L _ hn avl i_�esf v r� ate, { <br /> Inspection Form Included:Q OO 2 D� <br /> -Comments Included: �D' <br /> usiness Rep's Signature. Phone Number Inspec r s•Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 0 X A M P L�Z Z 3 62081 <br /> . White Copy:CIWMB Yellow Copy.Operator Pink Copy.LEA ■ <br />