Laserfiche WebLink
.4 a: Waste Tire SL*y & Inspection Reportolnspection Report Number <br /> �. " State of California <br /> CIWMB1811(New <br /> Manage) Survey Form - Page 1 <br /> California Integrated Waste Management Board ._... <br /> Part A Survey BLUE OR BLACK INK PEN <br /> . , <br /> Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: #� / ! I <br /> L / Q Routine Q Re-inspection Q Referral Q Observation <br /> Localf mm If Referral,choose referral type(Fill one) <br /> Identifier: [ Z7 1 , / <br /> (�Q Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> �j_ CC Inspected By Inspector <br /> i ! i i fC.J� V <br /> Physical Addressl��- !� - �p '1,&( AOS' <br /> 12 <br /> ftp <br /> Street p Q t <br /> �r L ���o L/ Ins ection Date / ! { <br /> r- TI <br /> <., Sfafeop ;oz Time In Time Out <br /> Business Rep Title <br /> O AM � O AM <br /> r1 ! 0 PM0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that appply) (Fill all that apply) (Fill all that apply)Count (Wholef <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered ` <br /> GPS Latitude 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 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 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date ID / I]] <br /> 11-1 <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 /> 0".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 /> Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> Ion- L1 iy. ,ct Ut/ ow,-i >✓ /A� -� <br /> / . <br /> `�) )---c�'' <br /> �1_.--f <br /> Inspection Form Included: Q <br /> Comments Included: 0 _ <br /> Business Rep's Signature Phone Number Inspector,Signature Phone(lumber <br /> - <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: ' r Vit, , ,� t r 3 1 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:OperatorPink Copy:LEA ® . <br />