Laserfiche WebLink
® c Waste Tire Sut"& Inspection Reportooection Report Number <br /> State of California <br /> CIWMB 0410 <br /> 1141182 <br /> California Integrated181 <br /> Was eeManagement Board Survey Form�m� - •P age 1 <br /> Part A Survey BLUE OR BLACK INK PEN <br /> tusiness Praftle ;:Irrspe�to Details <br /> �.,: _ . <br /> Inspection TPID- i { i p on Type (Fill one) <br /> Site Suffix. ' ^ <br /> L_�. LQ Routine Q Re inspection Q Referral 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 <br /> Inspected B <br /> p y Inspector <br /> Physical Address- <br /> I__........ _ � : _ ....._ _n._.___ ................._........._........_............. - <br /> l p 7 <br /> Inspection Date ` <br /> _ 1 <br /> mm Sial �Cod� Time In Time Out <br /> o <br /> Business Rep Title Q AM _... I <br /> ..... <br /> '._ P M <br /> O PM <br /> _... .___._._ tT....... - <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill athat aapI <br /> y) (Fill all that apply) (Fill all that apply)TCWTQ <br /> Active Q Passenger Q Generator Q Outdoor <br /> GPS Latitude <br /> O Q Closed {) Altered <br /> ` <br /> E Q Hauler Q Indoor <br /> �- ��.•` Q Inactive Q Truck <br /> Longitudel <br /> - j • Q Planned Q t Q End-use Q Container <br /> ry nest pe (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 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 /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date IE <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 0 Referred I 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 Qin Compliance - No Violations <br /> Q Q Other: § <br /> (�, 1y I I _ <br /> Comments LtJ t` ` ..,� _ ' 0 r <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector-.'s Signature ���: Phone Number <br /> __ .. <br /> INSTRUCTIONS ON BACK Correct: incorrect: ^ATT 62081 <br /> ® White Copy:CIVVMB Yellow Copy:Operator Pink Copy:LEA <br />