Laserfiche WebLink
Waste Tire Sy & Inspection Repo nspection Report Number <br /> California ate of California <br /> &rnia CIWMB 181(New <br /> Manage) Survey Form - Page 1 11 Q 6 4 9 <br /> ifornia Integrated Waste Management Board .___. __..._ ..._-_- _.__. .. -. _ J <br /> Part A- Survev BLUE OR BLACK INK PEN <br /> 20 <br /> TPID- "� Inspection Type (Fill one) <br /> Site Suffix: �� �� , T Q Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> - -- <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address Address% c� <br /> Street <br /> ^ <br /> Inspection Date <br /> I, V\� <br /> Citi y- State ZIP Code I Time InTime Out <br /> _ <br /> Business Rep TitleE�] Q AM m ; m Q AM <br /> O PM { O PM <br /> amm <br /> t, Operational Status Tire TypeTIM, Business Role S rage Type <br /> (Fill one only) (Fill all thatp PJ� (Fill all that apply) (Fill all that apply) <br /> Tire Count(VVholF' <br /> leTF) <br /> r <br /> Q Active 0 Passe" Q Generator (9 Outdoor <br /> O 0 Closed 0 Altere <br /> GPS Latitude „ �' M"r9 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck rw_, <br /> LU" <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all tial 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 /> - - --- <br /> VA HAULING AND MANIFEST REQUIREMENTS <br /> 0 ' 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 Notice Of Violation 0 Extension <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 I Date <br /> M / M / m <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 /> I <br /> 0 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 /> OO <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0,1n, Compliance - No Violations <br /> 0 0 Other: § ---------------- <br /> _— <br /> Comments <br /> Inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector',s Stgnafure Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X "�, % <br /> A V, P L E, 112 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />