Laserfiche WebLink
Waste Tire Suit . y & Inspection Report nspection Report Number <br /> ibis( State Bof CaliforniaClW114118 3 <br /> ew 04/0 <br /> California Integral d'Was81 tJe Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> %� <br /> TPID- Inspection Type (Fill one) <br /> '� ` � � V <br /> Site Suffix ! 5 i o - <br /> Routine Q Re-inspection Q Referral Q Observation <br /> 11 <br /> Local1 r If Referral,choose referral type(Fill one) <br /> Identifier: l_..:t C\ 10 1 L� >{ l U U{1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 4 <br /> rI Sri - - <br /> Physical AddressFT( o Pyt) E3(o*A <br /> e l <br /> Street {{{ Inspection Date �0 [71 <br /> f•f "� Time In Time Out <br /> Urt; S,ra e ZfF'L'v��e <br /> Business RepTitle I AM Q AM <br /> O PM PM <br /> rr -„ <br /> Operational)Status Tire Type Business Role Storage Type <br /> Tire Count Whole/PTE) Fill one only) Fill all that apply)I (Fill all that apply) (Fill all that apply) <br /> Active Q Passenger Q Generator Q Outdoor <br /> Latitude Q Closed Q Altered <br /> GPS <br /> I ! • O 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 /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Ret reader Q Dismantler Q Tire Derived Fuel <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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — Q Notice Of Violation Q Extension <br /> Q 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 /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 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/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q0 14 CCR§18462 Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance - No Violations <br /> Q Other: § J <br /> Comments � t <br /> S . <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> - <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �i Xs A ML 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> I <br />