Laserfiche WebLink
® ii.d Waste Tire Sft & Inspection Reporspection Report Number ■ <br /> 862 State of California <br /> �r <br /> CWMB 1(New04104) Survey Form - Page 1 Il - 1140857 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 3 O 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local 7 If Referral,choose referral type(Fill one) <br /> Identifier: CV4 jvct� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address 3Amavdc, <br /> Inspection Date l <br /> Time In Time Out <br /> Business Rep Title ® <br /> f� O AM O AM I _ . -� �--- -1 � - <br /> ® PM ® PM ! <br /> --- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) . (Fill all that apply), <br /> Tire Count(Whole/PTE) f f <br /> Active Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude I 0 Hauler 0 Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> ® 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 /> P , <br /> i V A 1 HAULING AND MANIFEST REQUIREMENTS 0 Notice of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires j <br /> 0 0 1 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 pate / <br /> 0 0 14 CCR§ 18459.1 -Tire Program ID Number from CIWMB m m m <br /> 0 0 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 ! 0 i 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 kefelrr d!MME 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 /> I In Compliance - No Violations <br /> 0 0 Other: § <br /> Comments <br /> -- <br /> Inspection Form Included: 0; P <br /> Comments Included: <br /> ,� — ---- g - ----��CJ�j� qII <br /> Busin ss Re s i net a hone Number Inspector's Si nature Phone Number <br /> '7 f --- <br /> INSTRUCTIONS ON BA K �Cort�et� corrc ,� � , s2oa1 <br /> �_.,..�� h` ..� �.,.., 1 2 3 <br /> e Copy:CIWMB Yellow Copy:Operator Pink Cop :L <br />