Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 1 2 - 1 01 4 7 8 4 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: f I J ® OO O <br /> I ` d 0 ` Routine Re-inspection Referral Observation <br /> Local � If Referral,choose referral type(Fill one) <br /> Identifier: 5, �r O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> . Inspected By Inspector <br /> Physical Address 3 <br /> Inspection Date d <br /> Time In Time Out <br /> Business Rep Title � AM 0 AM <br /> Q PM 0 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 /> 5C) d Active a Passenger ®Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude 0 Hauler ® Indoor <br /> O Q Inactive Q Truck <br /> Longitude — - Q Planned Q OTR 0 End-Use Q Container <br /> ' Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair Q Trucking Fleet 0 Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauier O Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V I A HAULING AND MANIFEST REQUIREMENTS Q Notice of Violation O�Extan;)an <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> i <br /> O 0 PRC§42953-Contracts with Registered Waste Tire Haulers. j Compliance Deadline <br /> Q 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 Q 14 CCR§18459 -Responsible Entities Complying with Manifesting RequirementsDate / m <br /> O O 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIW MB EE <br /> 0 Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV dr. T1 <br /> 0 Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred101 ilVftll <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 1 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators y <br /> � � -C�ttltp�A <br /> Other: § I�_:n77. <br /> « <br /> Comments I <br /> h'T'S �.� Dns r f-ri lj%.ICr r.-. �y�- ��3•'�'r �-..,�.�.5 -- - <br /> -�-.1.� e,,..,�.�-.�,. -�,y.� C���! y� f��f - a 6 I Iv f�-� � �✓f # l oac(�s�' -5'�t aBf��. <br /> d44 f i-zz-D�^ V I f�-f��, .5 <br /> Inspection FormIncluded: Q� <br /> Comments Included: Q <br /> Business R 's Signature Phone Number ins tor's Sig Phone Number <br /> INSTRUCTIONS ON BACK i Correct:* Incorrect: {�} lG A P j 62081 <br /> ---- .- ------ __.. <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />