Laserfiche WebLink
Waste Tire Sur j & Inspection Report 'ispection Report Number <br /> ,.� <br /> State of Survey Form - Page 1 13 - 0 6 4 Z <br /> CIWMB 181(New ry <br /> California Integrated Waste Management Board y <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I / Inspection Type (Fill one) <br /> Site Suffix: % '� 9 � �/ � - � � Routine QRe-inspection QReferral <br /> Q Observation <br /> Local . If Referral,choose referral type(Fill one) <br /> Identifier: Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> p Y Inspector <br /> Ye CPhysicalA �/<�.a� <br /> Inspection Date 12-- <br /> 2 / 7 <br /> Time In Time Out <br /> Business Rep Title _ Q AM Q AM <br /> O PM QPM Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 10 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f ® Active 0 Passenger 0 Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 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 EN VIENT STATUS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires j Q Eztenslo <br /> Notice Of Violation <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 IE <br /> 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 <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 0 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 I; <br /> ' ns <br /> Q 1 Q Other: § <br /> Comments ��I l('�' <br /> Inspection Form Included:0 Q" <br /> Comments Included: Q v <br /> Business Rep's Signature Phone Number. I sp toPhone Number <br /> INSTRUCTIONS ON BACK F 11121 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />