Laserfiche WebLink
Waste Tire :,,Ji .:y & Inspection Repot' Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 619 <br /> California Int grat d Wast 181(New <br /> Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK_ INK PEN <br /> Business Profile Inspection Details <br /> TPID- J 4 3 � - (� ' Inspection Type (Fill one) <br /> Site <br /> Site Suffix: ` `J ®Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Sq n 1 omAAl n pk 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V Inspected By Inspector <br /> Physical Address � 0 <br /> w <br /> Inspection Date u � o L � 1 <br /> Time In 1 Time Out <br /> Business Rep\ ' Title 016 AM C ® AM <br /> O PM J © PM <br /> - - -- - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) t (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> �p ® Active 0 Passenger ®Generator 0 Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive IS Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer ® Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 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 /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / 0 <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred f CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 , 0 Other: § <br /> Comments1 1 <br /> S n�1 _sLC, <br /> Inspection Form Included: 0 1 I► <br /> i Comments Included: <br /> k -3���- <br /> Business Rep's Signature Phone Number Inspect 's ignature Phonl��e Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect `�;. �/� �{ �¢, PT� Tj <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />