Laserfiche WebLink
- Waste Tire Sur. y & Inspection Report Ispection Report Number <br /> NA <br /> State B California I 1 - 1140557 <br /> Cgrated Waste <br /> eManag ) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey _ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> 3 d <br /> Site Suffix: ® 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 /> �6vr <br /> Business or Facility Name Inspected By Inspector <br /> Physij Address .3 <br /> qO© W , <br /> Inspection Date 0 <br /> 11537?1, <br /> Time In Time Out <br /> Business Rep Title5 11 _ O AM O AM <br /> 4 <br /> 6 3 ® PM 0 OPM <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 /> ' 0 Active Q Passenger Q Generator 1 Q Outdoor <br /> Latitude 0 Closed Q Altered <br /> GPS Q Hauler Q Indoor <br /> 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 Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hau!ar 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 014 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q 014 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> wry r �-wdt-� <br /> Inspection Form Included: Qi <br /> ��a4��� -+o�z <br /> Comments Included: ®II -- - - - i <br /> - Business Rep's Signature Phone Number spector's Signature _ Phone Number <br /> - --— <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X� � �/� E:X A L � � � <br /> White Copy:CIWMB Yellow Copy:Operator Pink C y:L <br />