Laserfiche WebLink
r Waste Tire Survey & Inspection Rept, c Inspection Report NumberState of ■ <br /> CIWMB1811(New 04104) Survey Form - Page 1 I1 - 1141037 <br /> California Integrated Waste Management Board J J <br /> Part A- Survey -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- 1 � 1 � � � � - O I Inspection Type (Fill one) + <br /> Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local / f If Referral,choose referral type(Fill one) <br /> Identifier: SQ� J !l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physic I Address 3 O 1 Pan E3(dt d <br /> nspection Date I / 3 ' Q <br /> la � cAIsa� I <br /> 0 a <br /> Time In Time Out <br /> Business Rep Title ( f� L� [ 10 AM AM <br /> 1 0 ` J O PM 5 O PM <br /> 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 /> ' Q Active Q Passenger Q <br /> Generator Q Outdoor <br /> PSLatitude O ® Closed Q Altered AVIA q /� <br /> G �/• Q Hauler Q 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 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 ® Other P"�w � �U11 <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCE NT STATUS <br /> V j 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 1 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 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 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 <br /> ® In Compliance - No Violations <br /> QQ Other: § <br /> Comments �j f <br /> r 1 <br /> Irl - - --- - <br /> flo- <br /> an <br /> InsP ection Form Included: Q �j �/ k lel <br /> Comments Included: - 04 L� !-!� <br /> ��B siness ep's Signature Phone Number Inspec s Signature one Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X El <br /> AL _' a t 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C p <br />