Laserfiche WebLink
Waste Tire Su &Ins Inspection Re Or Inspection Report Number <br />y p p <br />=, State I3 California Survey Form - Page 1 Il -1088382 <br />CIWMB 181 New 04/04) <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 />Site Suffix: f: �� LJL0 Routine 0 Re -inspection 0 Referral 0 Observation <br />Local - i If Referral, choose referral type (Fill one) <br />Identifier: 0 CHP _ 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br />Business or Facility Name Inspected By Inspector <br />Physical Address (� /' <br />Inspection Date <br />State Zd(� Code <br />1 <br />`ri r. <br />- u -J I Time In Time Out <br />Business Rep Title j ` 0 AM - �: ET 0 AM <br />'Jg IN Operational Status Business Role <br />,r- d�F�,:�, _ (Fill one only) (Fill a!1 that apply) (Fill all that apply) <br />„ <br />Tire Count Wholl6l " ' " <br />0 Active 0 Passenger 0 Generator <br />O 0 Closed 0 Altered <br />GPS Latitude 0 Hauler <br />O 0 Inactive 0 Truck <br />Longitude — Planned QTR <br />0 End -Use <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 0 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 F ENFORCEMENT STATUS <br />V A ! HAULING AND MANIFEST REQUIREMENTS 0 Notice Of Violation 0 Extension <br />0 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <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 m / m <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 />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 / 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 0 In Compliance - No Violations <br />0 -0 Other: § - — <br />Comments <br />Inspection Form Included: <br />Comments Included: <br />INSTRUCTIONS ON BACK <br />eWhite Copy: CIWMB Yellow Copy: Operator F'FnK copy: LEA ®7 _ <br />