Laserfiche WebLink
Waste Tire Su, .ay & Inspection Report Inspection Report Number ■ <br /> CIWMB 811ifornia(New 04/04) Survey Form - Page 1 I 1 1143982 <br /> California Integrated Waste Management Board Y J <br /> Part A--_Survey__ _- _-__- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- r -7 - © Inspection Type (Fill one) <br /> Site Suffix: ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \r��' If Referral,choose referral type(Fill one) <br /> Identifier: Sil Jw� � ����(� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> It I <br /> &A G, 'l Im lq <br /> Physical Address <br /> Inspection Date } '7 / > <br /> Time In Time Out <br /> Busine`s-s Rep Title O AM ! O AM <br /> P m <br /> PM <br /> --- -- ---- -- - - -- --- - --- - Operational Status Tire Type Business Role Storage Type <br /> ,c-�� (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) ��/ <br /> r ®Active oe Passenger ® Generator ® Outdoor <br /> Latitude 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 ® Agriculture Q Shredder Q Other <br /> i <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 i e 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 0 In Compliance - No Violations <br /> Q O (Other: § <br /> Comments <br /> (Inspection Form Included: Q <br /> 4er -- <br /> Comments Included:® -- — <br /> Business Rep's Signa re Phone Number IS' nature Phone Number <br /> � <br /> INSTRUCTIONS ON BACK Correct: Incorrect XI __ I II1 2 3 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Cop LE <br />