Laserfiche WebLink
■ ■ <br /> Waste Tire S y & Inspection Reports, <br /> Report Number <br /> "` State of California Number— <br /> Q. CIWMB 1 teManage) Survey Form - Page 1 1 7 - 1 0 0 8 0 8 0 <br /> Cahforr5ia Integrated Waste Management Board <br /> Part A- Survey .BLUE OR BLACK INK PEN <br /> r1Ptlt( n t� tl ' ='` � 3Y rsa ." <br /> f TPID- i Inspection Type (Fill one) <br /> Site Suffix: 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> _._.._._ <br /> Local �- If Referral,choose referral type(Fill one) <br /> Identifier: - - <br /> _ { , 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> ��r Inspected By Inspector <br /> Physical Address — <br /> / <br /> Street <br /> Ins <br /> pection Date <br /> City State ZIP Code Time In _ Time Out <br /> Business Rep / Title 00 AM PM E—]:] 0 AM <br /> 0 PM <br /> „fOperational Status r i r'1 Business Role " <br /> L r t r <br /> (Fill one only) g�#t ��� (Fill all that apply) �" Yffs� t <br /> /� �� )� � ) '- � ��✓��°�����'��,��,r�', torr){e11af�+>"�wt� i�,Iti <br /> ® Active ( a ��� �, Q Generator <br /> 0 <br /> Closed "77 . y✓( '�"S"r"i"�' n ^ F"r/ + <br /> Latitude r"r9�rf Jn�u <br /> GPS prrytrh m t , <br /> O Hauler r`c � 'rrG ✓ <br /> 0 <br /> Inactive L �� <br /> O 4�dIwr,4ty�t � y,int,, � k*� ltt va�fr r <br /> r <br /> Longitude — mn t t ru9*t� t 0 End-Use <br /> 0 Planned � i� ���+>��,�as/; <br /> New Tire Dealer Auto Repair 0 Trucking Fleet 0 Government 0 Re'treader 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 Notice Of Violation 0 Extension <br /> 0 0 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 ED / [DELI <br /> ® 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 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 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 /> Inspection Form Included: 0 <br /> Comments Included: 0 _ - <br /> Business Rep's Signature Phone Number inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X 1- :x A 62081 <br /> ■ -White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />