Laserfiche WebLink
-aE.,. <br />Waste Tire Suy &Inspection ReporInspection Report Number _■ <br />aha&" State of California S <br />Califom�lntegrat d Was epanagement Board 'Survey rvey Form --Page 1 I 1- 1 088424 <br />Part A - Survey BLUE OR BLACK INK PEN <br />Business Profile i Inspection Details <br />ix: 1j C} t✓ ri r -t; ! i Inspe <br />Site.SuffTPID ction Type (Fill one) <br />_... --.. <br />Q Routine 0 Re -inspection 0 Referral 0 Observation <br />Local If Referral, choose referral type (Fill one) <br />�- Identifier: I Gi.. A' 0 CHP 0 CIWMB 0 Complaint Q Educational Visit 0 Other <br />Business or Facility Name <br />% , <br />0 Notice Of Violation 0 Extension <br />Inspected Ins B <br />P Y <br />Inspector <br />00 PRC §42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline a <br />lC-t✓ <br />0 0 I PRC § 42956 - Registration/Decal in Vehicle <br />0 I 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Business Rep's Signature <br />- i - -- <br />Date m <br />Inspector'stitignature <br />- — - - <br />0 0 , 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Physical Address <br />INSTRUCTIONS ON BACK Correct: <br />eWhite <br />Incorrect: X (j .�%/E1 <br />L ��I � j � <br />��r � <br />r: G ''C �=✓G( 4i I <br />f?. <br />0 0 i 14 CCR §.18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />E <br />�' <br />0 0 14 CCR § 18460:2 - Manifest System Requirements for Registered ''Waste Tire Haulers <br />Street <br />0 Referred I CIWMB Enforcement <br />62081 <br />Inspection <br />Date % <br />Pink Copy:'LEA <br />■ <br />0 0 14 CCR § 18462 - Manifest.System Requirements for Tire Dealers or Waste Tire Generators <br />Q In Compliance No Violations <br />0 0 Other: § <br />- <br />City <br />Business Rep <br />State ZIP Code <br />Title <br />Time In <br />AM <br />Ll <br />O <br />Time Out <br />0 AM <br />Q <br />i� r//d <br />PM <br />PM <br />Operational Status <br />Tire Type <br />Business <br />Tire Count (Whole/PTE) <br />%� <br />(Fill one only) <br />(Fill all that apply) <br />Role <br />(Fill all that apply) <br />Storage Type <br />(Fill all that apply) <br />(3 Active <br />O Passenger <br />I @ Generator <br />O Outdoor <br />GPS Latitude <br />� <br />. <br />0 Closed <br />0 Alt dere <br />1' 0 Hauler <br />0 Indoor <br />0 Inactive <br />0 Truck <br />O <br />Longitude .- <br />0 Planned <br />0 OTR <br />0 End -Use <br />0 Container <br />Business Type (Fill all that apply) <br />! 0 New Tir'e�Dealer 0 Auto Repair 0 Trucking Fleet (2) Government 0 Retreader 0 Dismantler <br />I` <br />i0 Used Tire, Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br />0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br />Part B - Inspection of Waste Tire Dealer., Generator, Hauler and End -Use Facility I ENFORCEMENT STATUS <br />0 Tire Derived Fuel <br />V A I HAULING AND MANIFEST REQUIREMENTS <br />0 Notice Of Violation 0 Extension <br />0 I 0 PRC § 42951 - Waste Tire Hauler Registration and Transport of Tires <br />00 PRC §42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline a <br />0 0 I PRC § 42956 - Registration/Decal in Vehicle <br />0 I 0 14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Business Rep's Signature <br />- i - -- <br />Date m <br />Inspector'stitignature <br />- — - - <br />0 0 , 14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />INSTRUCTIONS ON BACK Correct: <br />eWhite <br />Incorrect: X (j .�%/E1 <br />0 0 14 CCR § 18459.2.1 - Submittal.of Comprehensive Trip Logs Within 90 days <br />(Required for NOV or EXT) <br />f?. <br />0 0 i 14 CCR §.18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />E <br />0 0 14 CCR § 18460:2 - Manifest System Requirements for Registered ''Waste Tire Haulers <br />3 <br />0 Referred I CIWMB Enforcement <br />62081 <br />0. 0 14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />Yellow Copy: Operator <br />Pink Copy:'LEA <br />■ <br />0 0 14 CCR § 18462 - Manifest.System Requirements for Tire Dealers or Waste Tire Generators <br />Q In Compliance No Violations <br />0 0 Other: § <br />- <br />Comments <br />1 1�r �% G <br />�,L t <br />Inspection Form Included 0 <br />Comments Included <br />- <br />Business Rep's Signature <br />- i - -- <br />Phone Number <br />- - <br />- - - - - - - <br />Inspector'stitignature <br />- — - - <br />Phone Number <br />- - - -1 <br />INSTRUCTIONS ON BACK Correct: <br />eWhite <br />Incorrect: X (j .�%/E1 <br />.A* <br />f?. <br />,I: <br />E <br />3 <br />62081 <br />Copy: CIWMB <br />Yellow Copy: Operator <br />Pink Copy:'LEA <br />■ <br />