Laserfiche WebLink
Waste Tire S e & Ins Inspection Re o% Inspection Repo <br /> til State of California Y I� Repo% <br /> +�� 7 I <br /> California lntegrat d WasCWMB 181 te Management Board ew 04/04) Survey Form - Page 1 1 9 - 10 0 V V f 1) <br /> Part A- Survey- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: L? �j 3 ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local f If Referral,choose referral type(Fill one) <br /> Identifier: �a,� ��'� V�_ l�p�NK '� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name _ <br /> Inspected By <br /> Inspector <br /> Physical Address <br /> -yl l E_ ' <br /> Inspection Date ` � � � � � � <br /> l.. <br /> Time In Time Out <br /> Business Rep Title ® AM ® AM <br /> 0 PM ,WPM <br /> > `[ Operational Status Tire Type Business Role Storage Type 1 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) �(, d <br /> ® Active ®Passenger ® Generator Outdoor <br /> 0 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> 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 /> _ _ --- <br /> I^V A HAULING AND MANIFEST REQUIREMENTS <br /> '!0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 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 / m <br /> 0 0 14 CCR§ 18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required forNOVorEX7) <br /> 0 1 0 14 CCR§ 18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers eferrey 1 CI MB _B o�t erne t <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities " / �w , <br /> � � � ,err �. <br /> 0 I 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> ® In Compliance No w ations <br /> 0 LD Other: § <br /> -- --- -- — ------ -- <br /> Comments ` M j <br /> qv t b�,( L w(s j vk, _ <br /> 1:r-c S 'co- 5A- <br /> 'inspection Form Included: 0 <br /> 0 Cud ' �t - �43Ii( s3 <br /> Comments Included: - - -- <br /> Bus Hess Rep's Signatur Ph a Number Inspector's Signature - Phone Number <br /> INSTRUCTIONS ON BA K �Correct: Incorrect:' ( _, ,X A'Ah P 2 62os1 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />