Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> Iq State of Callfornia <br /> ClWMB 1st(New Manage1 Survey Form - Page 1 1 2 - 1 0 2 5 8 0 7 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> !Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ` 3 d - d ` ® 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 /> Business or Facility Name <br /> r _ Inspected By Inspector <br /> Physical Address <br /> A,G,r"4y._ <br /> Inspection Date C.7 <br /> Time In Time Out <br /> Business Rep Title O AM O AM <br /> LAZ �w1r..¢�J O PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I> <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t t ® Active f�Passen er � Generator <br /> *Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler 0 Indoor <br /> o Inactive ®Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> 1 Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Govemment 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 it Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility `ENFORCEMENT STATUS <br /> V1. A I HAULING ANIS MANIFEST REQUIREMENTS <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Notice Of Violation Q 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 pets I / 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 /> 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 D+lif#Tslred(.CIYVIN6 Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ _ __- <br /> i <br /> 0 0 14 CCR§18462-Manifest System Requirements For Tire Dealers or Waste Tire Generators _ <br /> #f4 P110 illip" No Violations <br /> 0_ 0 Other: § <br /> Comments C ll ✓ <br /> Inspection Form Included: QI y 7 1 ✓ [� r p <br /> Comments Included: <br /> us no s 's Signa Phone Number Inspector's$Ignature Phone Number <br /> INSTRUCTIONS ON BACK Corrects ntro�`rtst [ � 11PI_ 4.1.1� 1 � 6zos1 <br /> White Copy CIWMB Yellow Copy:Operator Pink Copy:LEA <br />