Laserfiche WebLink
r ' Waste Tire Sy & Inspection Repo inspection Report Number <br /> State California 11 1141308 <br /> CIWMB 181(New urvey Form - Page 1 <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 0 ® Routine Q Re-inspection Q Referral Q Observation <br /> Local ,n j' If Referral,choose referral type(Fill one) <br /> Identifier. �r l t( ' Oil 4XA / Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v Inspected By Inspector <br /> PhysICI�A dres� 't� -! 1 � �✓Ic� ��L �Vr�- `Z _ <br /> -79 7 } <br /> Inspection Date / v/� <br /> Time In Time Out <br /> Business Rep TitleO AM Q AM <br /> 0 PM ® PM <br /> -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ®Active ®Passenger Generator j Outdoor <br /> -- - D Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude — I Q End-use Q Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> *New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> ®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 ; A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m , m <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 /> 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 Wn Compliance - No Violations <br /> Q Q (Other: § <br /> Comments <br /> Inspection Form Included: 6 <br /> Comments Included: - #igture <br /> Business Re s i re Phone Number In e t Phone Number <br /> -INSTRUCTIONS ON BACK Co rec : Incorrect: XEXa; f� 62081 <br /> White Copy CIS P Yellow Copy:Cpe-ator Pink Copy:LEA <br />