Laserfiche WebLink
Waste Tire Su :y & Inspection Report Inspection Report Number <br /> State CIWMB California I 1 — 110 4 0 2 <br /> grated Waste <br /> eManag) Survey Form - Page 1 _ <br /> California Integrated Waste Management Board _ <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I � � � O � R_ - <br /> lJ Inspection Type (Fill one) <br /> Site Suffix: 0 ( 0 Routine 0 Re-inspection 0 Referral 00 bservation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: !��'l J �Ct d t t o i^_Y�f 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> rr ' Inspected By Inspector <br /> I I re131ro 4 til go r'r?eyL1 <br /> Physical Address 3 "1 I U `7c,,k,� FTq sg/ <br /> Street <br /> l Trc((j 3' / <br /> I Inspection Date <br /> City (State ZIP Code Time InTime Out 1 <br /> Business Rep Title (J O AM r Q AM <br /> N/A �` aPM l/ � ' V QPM <br /> L t 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 /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS Latitude <br /> O ® Closed 0 Altered <br /> � . <br /> 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 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 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / PI <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 0 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: § l_ [ <br /> Comments c3 )k( _ , o I i "Gt _ 1�I 0 W <br /> vj E'ki Q u, of _/Jo J r V,I L4-,r <br /> t"! til a(n I C Y� OVt v� �. L)O j:1 . <br /> r <br /> Inspection Form Included: 0 <br /> Comments included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X Ak � �� I 62081 <br /> � rr ?�:IA, l4'�lr, �iEl � 2 . <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />