Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Su&y & Inspection Report <br /> HHIN SM Ctate of California t <br /> Califom lntegrat d181(Newste 0410ement Board Survey Form - Page 1 1 6 r 10 1 i � <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- _ Inspection Type (Fill one) <br /> Site Suffix: Q - <br /> U � � ✓ � � / ® Routine Q Re-inspection Q Referral Q Observation <br /> Local6011 <br /> If Referral,choose referral type(Fill one) <br /> Identifier: r r .-. , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title O AM O AM <br /> 0 PM Q PM <br /> Operational Status Tire Type Business Role orage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) Fill all that apply) <br /> Tire Count (Whole/PTEJ U <br /> Active 0 Passenger 0 Generator Outdoor <br /> O 0 Closed Altered <br /> GPS Latitude 0 Hauler door <br /> O 0 Inactive 0 Truck <br /> Longitude — F T-1 0 Planned OTR 0 End-Use ontainer <br /> usine'sFill 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 0 _-- - 0 Notice Of Violation 0 Extension <br /> 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 0 / 0 / 0 <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 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 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: § <br /> Comments <br /> ,�. _ r <br /> cl, }� r c LI �{ < / TLS c rf <br /> Opttion Form Ynattided: <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector's Signature _ Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X i E X A hh P I L2 3' <br /> 1+ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> 0 <br />