Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State California I 1 - 1143473 <br /> CIWMB 187(New 04104) 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- /� �-] 1 Inspection Type (Fill one) <br /> Site Suffix: V � l�/ 0-a- l O 1 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ' <br /> \' If Referral,choose referral type(Fill one) <br /> Identifier: SU 1 O ut♦n Cn Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> __VVV_ <br /> Business or Facility Name Inspected By Inspector <br /> Physical A dress 1 6cn <br /> S�lr 1 101, J(� 0 f\ 0 A q`�U Inspection Date O 1 <br /> Time In Time Out <br /> Business Rep Title I I WAM <br /> 'l <br /> l Q 0 PM I Z V It PM <br /> \ <br /> -- -- - , Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � a (� <br /> ® Active *-Passenger ® Generator IS 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 /> New Tire Dealer Q Auto Repair 0-Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 /> - - <br /> A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q <br /> 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 <br /> M / M / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q 1 Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 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 Is In Compliance - No Violations <br /> Q Q Other: § --I <br /> Comments <br /> az <br /> ,Inspection Form�nded: QI! <br /> ® �z��4by 2-112-19 <br /> Commentsed: �r�'sSignaBusiness Rep's Signature hone Number/ lnspecure _ honeNumber_ <br /> • V l A M L 1 1 2 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: 1 <br /> ■ -- ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy L . <br />