Laserfiche WebLink
Waste Tire Swey & Inspection Repor Inspection Report Number <br /> - - <br /> iT+ State of CaliforniaC,W `/�� j/�� j�yj }/�R <br /> ew 04/04) <br /> California Integrated d Was181 te Management Board Survey Form - Page 1 �,/ �/ if 1,/ <br /> --,�. _..-- --._-. - 7 <br /> Part A- Surve BLUE OR BLACK INK PEN <br /> 00'i <br /> ..c ��u��_miG''f3' "_":• .fv, +t.'.' n"I " ��' ' �"'.�NOW <br /> �. <br /> TPID- / � Inspection Type (Fill one) <br /> Site Suffix: <br /> �'Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �, <br /> .. + ',-i � i•- 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Ph slca <br /> t ` <br /> I Address <br /> I / � ���-! / fl,��.` f..•. .,. 1.` � <br /> Street <br /> Inspection Date E / J ` / [ED <br /> city State ZIP Code Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> r . <br /> Q PM Q PM <br /> M : 1 T_ <br /> —' <br /> Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (t=ill all that apply). <br /> jai (3Y Active 0 Passenger Q Generator 0 Outdoor <br /> GPS Latitude � . 10 0 Closed 0 Altered >; 0 Hauler 0 Indoor <br /> 0 Inactive 0 Truck <br /> Longitude — ! Planned Q OTR 0 End-Use 0 Container <br /> Business Type (Fill all that 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 (RP 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 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires 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 Date 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 /> 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 a 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 /> d <br /> d <br /> l <br /> I <br /> F <br /> ti <br /> InS econ Form ncue ! i <br /> p ly a+',z,. <br /> Comments Included. 0 <br /> Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> / 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X A 101 ,, i <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ■ <br /> - l <br />