Laserfiche WebLink
= Waste Tire SL_ ✓ey & Inspection Repol Inspection Report Number ■ <br /> ka <br /> State CIWMB California I 1 - 1143583 <br /> 181 04104) <br /> California Integrated Was eeManagement Board Survey Form - Page 1 <br /> l"t A-SurveyBLUE OR BLACK INK PEN <br /> ness Profile Inspection Details <br /> .D- 1., Inspection Type (Fill one) <br /> Site Suffix: L - O ® Routine O Re-inspection O Referral O Observation <br /> Local \ /` If Referral,choose referral type(Fill one) <br /> Identifier: (z"a n )�r�C�,��n G>v�' O CHP O CIWMB O Complaint O Educational Visit O Other <br /> Business or Facility Name UV Inspected By Inspector <br /> WI\Yk , coo ) <br /> Physical Addres - <br /> /q� !-, Inspection Date <br /> JL� tt C���v� Time In Time Out <br /> Business Rep Title Z1 Z r) 4D AM AM <br /> QPM ' ® PM <br /> p �� V <br /> --- - n-�� - - - -------- -- ---- 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 /> le O Active O Passenger 0 Generator O Outdoor �n <br /> Latitude O ® Closed O Altered N/A <br /> GPS O Hauler O Indoor <br /> O O Inactive O Truck <br /> Longitude - O Planned 9 OTR O End-Use O Container <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair O Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> Jsed Tire Dealer O Auto Body O Car Dealer O Collection O Crumb Rubber <br /> O Service Station O Hauler O Agriculture O Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A J HAULING AND MANIFEST REQUIREMENTS <br /> O Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O 1 O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> M / M / m <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> i <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers O Referred/CIWMB Enforcement <br /> O 014 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In compliance - No Violations <br /> O O (Other: § <br /> Comments <br /> ,action Form Included: 0 r� .*� _ <br /> Comments Included: <br /> `—J�" <br /> Busi R s Signature Phone Number In a or's tura Phone Number <br /> - <br /> INSTRUCTIONS O K Correct incorrect: I (�, 71 <br /> 62081 <br /> - - Inco- - �y <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />