Laserfiche WebLink
Waste Tire Su y & Inspection Reporti Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I1 - 1088433 <br /> California Integrated WasttManagement <br /> Waste Management Board <br /> Part A- Survey _ _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection�� � � � � � Inspection Type (Fill one) <br /> 4jSite Suffix: v ® Routine Q Re-inspection Q Referral Q Observation <br /> Localc, If Referral,choose referral type(Fill one) <br /> Identifier: �]OL 1 ��n �t ,�'t'L�1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name / Inspected By Inspector <br /> Physical Address <br /> �T <br /> Inspection Date 1 7 / <br /> Time In Time Out <br /> Business RRitbt <br /> ep Title Cl 0 AM j Q AM <br /> Ay)��©�(U�ji�C'.1 1. e V- ® PM l 5 ® PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f Q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> l 0 Active ® Passenger ® Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive ®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 9 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> FV HA AULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> 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 <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 EXT) <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/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 ® In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> s <br /> Inspection Form Included: Q <br /> Comments Included: h�0 ") `x`'�Gd6 7 <br /> _ Business'ffer;"s_SignaMeVVj Phone Number 1 s or' gnature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incor t: 1E XIA IV 111213 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:L <br />