Laserfiche WebLink
® Waste Tire Sul* & Inspection ReporiGOpection Report Number <br /> S3n6 State of California ? <br /> -i CWMB grated Waste <br /> eManage) Survey Form - Page 1 11 - 114117 3 <br /> California Integrated Waste Management Board i <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile [nspett Detail` ^ A <br /> TPID- 1 i _� ( Inspection Type (Fill one) <br /> Site <br /> Site Suffix: (� ' <br /> — --� — 0 Routine ,Re-ins ection QReferral <br /> Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier. /� L Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> .__.._.._ .._- .. L.3................ ._�_.-.......... . _ _�,.._ U .........._ _..__._.,__..._..._..._ <br /> Inspection Date <br /> i <br /> '«1 `r�rcr0 Time In Time Out _. <br /> Business Rep Title0 AM 0 AM <br /> ...._..,.._ - <br /> OPM l OPM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(WholelPTE) i 1 (Fill one only) (Fill all that app, (Fill all that apply) (Fill ail that apply)' <br /> fU 1 �" <br /> (D Active Q Passenger Q Generator Q Outdoor <br /> . i ) [ <br /> O Q Closed 0 Altered <br /> GPS Latitude <br /> I ( Q Hauler Q indoor <br /> Q Inactive a TruckO <br /> Longitude <br /> Q End-Use 0 Container <br /> i Q Planned Q OTR <br /> Business Type (Fill all that <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 Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V sA !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 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 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 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments r 71 <br /> />r <br /> G <br /> inspection Form Included: 0 <br /> Comments Included; 0 <br /> Business Rep's Signature Phone Number Inspector's 5ignaVwe Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X62081 3 { 1 L - 62081 <br /> ® White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />