Laserfiche WebLink
Waste Tire Sui y & Inspection Report 'nspection Repor} Number <br /> 8383 State of California <br /> _ CWMB grated 1st(New <br /> Manag) Survey Form - Page 1 I 1 - 1141023 <br /> California Integrated Waste Management Board <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> i <br /> TPID- Inspection Type (Fill one) <br /> I 3 � <br /> Site Suffix: 6 S O ® Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: <br /> CA-All OCe C % C, y�,�-d Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name � (J- '"_ <br /> � Inspected By Inspector <br /> Physical Address 3 - (� &PX <br /> 'nn Inspection Date � 1 a I I <br /> Ayc)r C A �j s366 1 <br /> Time In Time Out <br /> Business Rep Title _ ® AM ® AM <br /> v U J O O PM ' O Q PM <br /> rQ �a t ��noY1 SU oft cko<I - - - - ---- ... <br /> r �� - 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 /> ' ' ® Active Q Passenger ®Generator ®Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler I Q Indoor <br /> 0 j Q Inactive * Truck <br /> Longitude - Q Planned Q OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair ® 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 <br /> 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 /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q O 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> Q O 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 O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O I O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 1 ® 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q i Q Other: § <br /> Comments <br /> Inspection Form Included: 01 <br /> Comments Included: ®' - - _,�� yJ ��_O <br /> Business Rep's Signature Phone Number nspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X �,. V Xt:�,A (. 1 2 62081 <br /> White Copy:CIWMB Yellow Copy.Operator Pink Co <br />