Laserfiche WebLink
iEl 'rt�- - <br /> Waste Tire y p p <br /> Su & Ins ection Repa Inspection Rep6rtlVuhber- <br /> ■ <br /> km <br /> State of Ca ifornia Tr it <br /> CIWMB 187(New,04104) Survey Form - Page 1 . .1 2 - 1 0 1 ' 06 6 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> } Site - tj , - Inspection Type (Fill one) <br /> Site Suffix: 0 D I 1 <br /> ,./ -'-! _ �@ Routine 0 Re-inspection 0 Referral 0 Observation. <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: o(T•Y ("(t4 (119Z.1 0: l 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - <br /> �{ ff ? ? Inspected By Inspector <br /> o <br /> Physical Address ,2 <br /> Street <br /> Inspection Date <br /> City State ZIP Code Time In Time Out <br /> Business Rep Title r0 AM 0 AM <br /> (. ��'!�/f r•�t/t ',/`,/ m ' m 0 PM m ' m 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) ❑ � P% �, (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> L (0 Active Passenger Q Generator 0 Outdoor <br /> O I 0 Closed 0:Altered <br /> GPS Ititude m . @ Hauler 0: Indoor <br /> D 0 Inactive � Truck <br /> Longitude - 0 Planned OTR @ End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dea er 0 Auto Repair 0 Trucking Fleet 0 Government O Retreader . 0 Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer O Auto Body O Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station Q Hauler O Agriculture 0 Shredder 0 Other <br /> 1 I <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFO_RC_EM_ ENT STATUS <br /> V : A HAULING AND MANIFEST REQUIREMENTS F <br /> 0 Q 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 /> O 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / IE <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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No violations <br /> 0 0 Other: § <br /> Comments f , / t / <br /> (i✓!6(C i t' <br /> �'r' �►;'!f`, ✓ 1/> �if� (_ U r J j;�� :" lrlJefo ,i <br /> J CaL��• ` { ``,� l�10_ i/I n; <br /> Inspection Form Included: OX! Y <br /> ` <br /> Comments Included. Business Rep s".Signature-! Phone Number I Inspector's Signature I (^I!Phone Number <br /> INSTRUCTIONS ON:B' AICK +Correct:0 Incorrect: X)� d iI EIXI.AIMI P I L I El JI],2 13 620811 <br /> ■ ! White Copy:CIWMB Yellow Copy-.Operator Pink Copy:LEA © ■ <br />