Laserfiche WebLink
Waste Tire Sufy & Inspection Repors Inspection Report Number <br />State of CaliforniacWMB /\ <br />w 04104) <br />califo�rrnla Int grat d'81 Wast eManagement Board Survey Form - Page 1 1 4 - 10 0 6 7, 7 5_ <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile Inspection Details <br />TPID - t 5, � - .� f Inspection Type (Fill one) <br />Site Suffix: <br />to Q Re inspection 0 Referral 0 Observation <br />- _ --- <br />Local If Referral, choose referral type (Fill one) <br />Identifier.1 ; r r ' • Q CHP CIWMB 0 Complaint Q Educational Visit 0 Other <br />Business or Facility Name (' Inspected By Inspector <br />Physical Address <br />4 <br />Q New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader <br />Q Used Tire Dealer <br />Inspection Date <br />0 Car Dealer <br />Street <br />i <br />', <br />0 Hauler <br />Q Agriculture <br />Citi v <br />Business Rep Title <br />State ZIP Code <br />Time In <br />j <br />® AM <br />Time Out <br />® AM <br />Q <br />O <br />! `✓ <br />l Q PM <br />Q PM <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />Operational Status Tire Type <br />Business Roleorage Typ <br />Q <br />Tire Count (Whole/PTE) � <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />� � <br />, <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) •(Fill all that ap <br />a <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q Active <br />O <br />O Passenger <br />Q Generator Q Outdoor <br />GPs Latituded <br />I <br />FT <br />OClosed <br />Altered <br />0 Hauler 0 Indoor <br />U�I <br />O Q Inactive <br />Truck <br />LO <br />Longitude - FTTT <br />O Planned <br />OTR <br />End -Use t in <br />Q New Tire Dealer Q Auto Repair O Trucking Fleet O Government Q Retreader <br />Q Used Tire Dealer <br />Q Auto Body <br />0 Car Dealer <br />® Collection <br />0 Crumb Rubber <br />( Service Station <br />0 Hauler <br />Q Agriculture <br />Q Shredder <br />(0 Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />O <br />O <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />O <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />O <br />14 CCR § 18459.1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />0 <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />Q <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />0 <br />O <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />0 <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />O <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />0 <br />O <br />Other: § <br />Dismantler O Tire Derived Fuel <br />ENFORCEMENT STATUS <br />O Notice Of Violation O Extension <br />Compliance Deadline <br />Date <br />/m/m <br />(Required for NOV or EXT) <br />O Referred / CIWMB Enforcement <br />O In Compliance - No Violations <br />Comments <br />J <br />'Al i/ <br />%4f f1(c'�. l RJ' j:t`�Gt/'✓ a �a{Q +✓f"} I ( , �>1{ �l' t rt it i�-�c/ 1`riF �� <br />Inspection t'orFn IneTur3ed: <br />Comments Included: 0 -- <br />Business Rep's Signature Phone Number Inspector's Signatur Phone Number <br />X , � 1 62081 <br />INSTRUCTIONS ON BACK Correct: Incorrect: ��i � � �C ft hh P I_ � I 2 3 <br />White Copy: CIWMB Yellow Copy: Operator Pink Copy: LEA <br />