Laserfiche WebLink
Waste Tire S,ur„ey & Inspection Repor L Inspection Report Number ■ <br /> State CIWMB California I 1 - 112 7 8 8 3 <br /> grated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> PartA- Survey -_ BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID_ - - ---� Inspection Type (Fill one) - - - — <br /> Site Suffix: I* Routine Q Re-inspection Q Referral Q Observation <br /> Local � A If Referral,choose referral type(Fill one) <br /> Identifier: J �j VLA C0wv)kA Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address �Q C1 Esq <br /> Ck 5� <br /> `�nLY l `C n <br /> CA 3'-�' Inspection Date <br /> • Time In Time Out <br /> Business Rep Title h 0 AM (7 AM <br /> V 4) PM O is PM <br /> -- -- - - - -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) a tq (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> O 4§ Active 0 Passenger Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler �� .� Indoor <br /> O Q Inactive • Truck <br /> Longitude - Q Planned Q OTR Q End-Use Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer 40 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> 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 /> VA j 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 /> i <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 /> M / m / 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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> IS In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> (Inspection Form Included: Q ]] <br /> Comments Included: e - t��� - �Q-� ~rn� _t <br /> lisines ep Signature hone Number Inspect s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct.* Incorrect X e X A L " I z 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pin Cop ■ <br />