Laserfiche WebLink
■ 'ii as Waste Tire . 0by Inspection a C� Inspection Report Number <br />it State of California ,may <br />CIWMB 04/04) <br />California Int grat d'81 Was eeManagement Board S _" " " ey Form - age I 11 — 1143791 <br />Part A - Survev BLUE OR BLACK INK PEN <br />Business Profile I Inspection Details <br />TPID - <br />Site Suffix: <br />— <br />Local <br />Identifier: <br />Business or Facility Name <br />V P act <br />Physical Address <br />Z_c ► (4. _ �1 Wo <br />Business Rep Title <br />Tire Count (Whole/PTE) t S b <br />O <br />GPS Latitude ° <br />0 <br />Longitude — <br />Business Type (Fill all that apply) . <br />Inspection Type (Fill one) <br />® Routine Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Inspected By Inspector <br />Inspection Date <br />Time In Time Out <br />0 AM ® AM <br />l O PM L O* PM <br />Operational Status <br />Tire Type <br />Business Role <br />Storage Type <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />* Active <br />Q Passenger <br />0 Generator <br />® Outdoor <br />Q Closed <br />Q Altered <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q Hauler <br />Q Indoor <br />Q Inactive <br />0 Truck <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q Planned j <br />Q OTR <br />Q End -Use <br />Q Container <br />Q New Tire Dealer Q Auto Repair ® Trucking Fleet Q Government Q Retreader <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 <br />V <br />A <br />HAULING AND MANIFEST REQUIREMENTS <br />Q <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />Q <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Q <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Q <br />Q <br />14 CCR § 18459.1 - Tire Program ID Numberfrom CIWMB <br />Q <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />Q <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Q <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />010 <br />1 Other: § <br />Comments iQ I_ - & �_ iQ_ <br />Inspection Form Included: 4Busi <br />Comments Included: ss Rep Signature Phone Number In <br />INSTRUCTIONS ON BACK Correct: Incorrect: I �, j X A <br />— tX <br />` <br />White Copy: CIWMB Yellow Copy: Operator Pink ( <br />Dismantler Q Tire Derived Fuel <br />FORC <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Datem/m/m <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />In Compliance - No Violations <br />62081 <br />® ■ <br />