Laserfiche WebLink
�`tYr Waste'Tire S y & Inspection Repo Inspection Report Number <br />cwMB81California <br />CIWMB Survey Form - Page 1 -1� 8 - .1 '0 0 8 10 4 -9 <br />California Integrated Waste Management Board <br />,,_Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile <br />A <br />Inspection Date <br />TPID - <br />,Site Suffix: <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires ry' <br />- <br />O AM <br />Time Out <br />O AM <br />m� <br />City <br />'Business Rep <br />t <br />State ZIP Code <br />Title <br />( <br />O <br />O <br />0 P <br />0 P <br />Tire Count (Whole/PTE) <br />a <br />O <br />[ 7 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />f <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />Local <br />Operational Status <br />(Fill one only) <br />Q} Active <br />O <br />Tire Type <br />(Fill all that apply) <br />) Passenger <br />Business Role <br />(Fill all that apply) <br />(?) Generator <br />Identifier: <br />(t) <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Business or Facility Name. <br />Inspection Details <br />Inspection Type (Fill one) <br />Q Routine ' Q Re -inspection Q Referral Q Observation <br />If Referral, choose referral type (Fill one) <br />Q CHP Q CIWMB Q Complaint Q Educational Visit 0: Other <br />Inspected By Inspector <br />- I O <br />vet <br />A <br />Inspection Date <br />O <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires ry' <br />Time In <br />[1] <br />O AM <br />Time Out <br />O AM <br />m� <br />City <br />'Business Rep <br />t <br />State ZIP Code <br />Title <br />( <br />O <br />O <br />0 P <br />0 P <br />Tire Count (Whole/PTE) <br />a <br />O <br />[ 7 <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />f <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />L <br />Operational Status <br />(Fill one only) <br />Q} Active <br />O <br />Tire Type <br />(Fill all that apply) <br />) Passenger <br />Business Role <br />(Fill all that apply) <br />(?) Generator <br />Storage Type <br />(Fill all that apply) <br />6 Outdoor <br />O O Closed � Altered <br />GPS Latitude m . � O Hauler 0.' Indoor <br />O O Inactive O' Truck <br />Longitude - O Planned OTR O End -Use 0 Container <br />Business Type (Fill all that apply) <br />New Tire Dealer . Q Auto Repair O 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 O Agriculture Q Shredder Q Other <br />Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End -Use Facility <br />V <br />A <br />'HAULING AND MANIFEST REQUIREMENTS <br />O <br />Q <br />PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires ry' <br />O <br />O <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />O <br />O' <br />PRC § 42956 - Registration/Decal in Vehicle <br />O <br />O <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />O <br />O <br />14 CCR § 18459;1 (a) (b) (c) - Tire Program ID Number from CIWMB <br />O <br />O <br />14 CCR § 18459.2.1 - Submittal of Manifest Forms and Tire Trip Logs within 90 days <br />O <br />O <br />14 CCR § 18459.3 - Retention of Manifest Forms and Tire Trip Logs for 3 years <br />O <br />O <br />14 CCR § 18460.2 - Manifest -System Requirements for Registered Waste Tire Haulers <br />O <br />O <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />O <br />(t) <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />n <br />n <br />Other: § • <br />ENFORCEMENT STATUS <br />Q Notice Of Violation Q Extension <br />Compliance Deadline <br />Date <br />(Required for NOV or EXT) <br />Q Referred / CIWMB Enforcement <br />O in Compliance - No Violations <br />Comments ��,G �, >� .•�..atJc S G! �.t1ct`i!G tri G'� -!'1 G `f c� �7 t <br />boo IL I,J.-H,. �/<�"T'C 41 <br />�iAIN <br />Inspection Form Included 00:1 R , <br />Comments Included: 0: j _.. - , _._ <br />Business Rep's Signature Phone Number. Inspector's Signature Phone Number <br />INSTRUCTIONS ON BAC Correct: Incorrect:) ( U �rPt F" 1 62081 <br />■ , 'I White Copy: CIWMB Yellow Copy: Operator — Pink Copy: LEA ® ■ <br />