Laserfiche WebLink
Waste Tire Su. ✓ey & Inspection Report Inspection Report Number ■ <br /> =o� State CIWMB California I ew 04104) 1 - 114 3 5 3 9 <br /> California Int grat d Was181 te Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details l <br /> TPID- - O � Inspection Type (Fill one) <br /> Site Suffix: "� Q Routine •Re-inspection Q Referral Q Observation <br /> Local 1 t If Referral,choose referral type(Fill one) <br /> Identifier: 5�(1 -V U&Iu.1n t(�t.(,1 til Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name 1 ' `J Inspected By Inspector <br /> O c(NI 0,f SCpl t�u�c� wt fo, <br /> Physical Address <br /> 1�-3'Y7 6 Inspection Date <br /> Time In Time Out <br /> Business Rep Title 10 AM %AM <br /> + , O 0 P �j QPM <br /> - - — -- - - - - Operational Status Tire Type Business Role Storage Type <br /> ` I w (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> + + 40 Active Q Passenger Generator Outdoor <br /> Latitude D Q Closed Q Altered <br /> GPS Q Hauler ® Indoor <br /> O Q Inactive Truck <br /> Longitude — Q Planned ® OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q 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 /> V I A I HAULING AND MANIFEST REQUIREMENTS11 <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q Q § 9 i 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 /> 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 /> i <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 Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators [!LnCompliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> j um <br /> t ^ <br /> Inspection Form Included: Q, //ll <br /> Comments Included: Q4g - J��3 3V <br /> usine s Rep's Signature Phone Number Inspecto +gnature Phone Number <br /> - 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X � �/ T <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink C py:L ■ <br />