Laserfiche WebLink
s Waste Tire Suoy & Inspection Repor{ .nspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I1 - 1141153 <br /> California Integrated WasttManage <br /> Waste Management Board .._....... ...... <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> P - <br /> Business Profile Inspection Details <br /> TPID- L1 Inspection Type (Fill one) <br /> Site SuffixT57 <br /> : l f Iz/ 1 -5 V ( I Q Routine Q Re-inspection Q Referral Q Observation <br /> Local �E ` ,1 C G 1 If Referral,choose referral type(Fill one) <br /> Identifier: ! �� \� t L S l C Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> C C' <br /> Street I <br /> \VI Inspection Date <br /> fpr e Z/PC,:}r/e� Time InTime Out <br /> _. <br /> I O AM 0 AM <br /> QPM 0P <br /> Business Re Title <br /> Operational Status Tire Type Business Role Storage Type <br /> 71, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> The Count(WhoIeIPTE) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> Latitude O a Closed Q Altered <br /> GP$ � • �__y ___�I, E � Q Hauler Q Indoor <br /> I � <br /> - 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 Retreader 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 Other �`� ( `E tY V <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> — <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <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 717 / m <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 /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ( In Compliance - No Violations <br /> Q Q Other: § <br /> Comments til F 11 t� }F< 121'1 t K3� C� ' f= <br /> it C I Cy <br /> } iC i1[ fGi1 C te root 'AlJe-t C� <br /> Inspection Form Included: Q <br /> Comments Included: Q > e f <br /> Business Rep's Signature Phone Number Insperttor's Signature Phone Number <br /> "' 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � �ta X A �.LEl,P i l� 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />