Laserfiche WebLink
■ Waste Tire Su Jy & Inspection Report Inspection Report Number <br /> CIWMB 81Cal1fornia(New 04/04) Survey Form - Page 1 I 1 - 1127707 <br /> California Integrated Waste Management Board ! V <br /> Part A- Survv�____- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` b O O Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �� 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 L� l 1 <br /> Inspection Date <br /> ACcA-mpo Time In Time Out <br /> Business Rep Title � 3 l2 0 AM 0 AM <br /> ® PM � (1 � ® PM <br /> a -- O �� Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive ® 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 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 /> ENFORCEMENT STATUS <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility <br /> --- - <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 0 0 Notice Of Violation 0 Extension <br /> 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 <br /> 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 /> 0 O — - -- - <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 <br /> in Compliance - No Violations <br /> 0 0 Other: § <br /> Comments ®r'1 1lf'Il � yV1 I,}21,�/-� <br /> Inspection Form Included: 0 t 9 <br /> Comments Included: 0 - ---�--f-1 L t�- ----- -- -- <br /> Business p's ignat a Phone Number I c ignature Phone Number <br /> - - - <br /> � i 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect Gfi �/ + l- � � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Co y:L ® ■ <br />