Laserfiche WebLink
■ =' Waste Tire SU*y & Inspection Reports Inspection-Report Number ■ <br /> State of California <br /> CIWMB 04/04) <br /> T J — 0 ^ t. <br /> California lne grat df81 WaseeManagementBoard Survey Form - Page 1 1 11 <br /> 884 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile _ Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> I I � *} <br /> I J IJ � b <br /> Site Suffix: � Routine Q Re-inspection Q Referral Q Observation <br /> Local // If Referral,choose referral type(Fill one) <br /> Identifier: f r f. ��� t Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name U Inspected B <br /> /11 r p Y Inspector <br /> DoJ qt, <br /> Physical Address <br /> 7 55r- <br /> Street <br /> I _ r Inspection Date C- <br /> City tate ZIP Code Time`In Time Out <br /> Business Rep Title O AM <br /> n / I Q AM <br /> PM (� <br /> � .I � `-' QPM <br /> 1 11 I <br /> J-1 Operational Status Tire Type Business Role Storage Type <br /> ) <br /> Tire Count Whole/PTE (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Ll` ' � ' Q Active Q Passenger Q Generator Q Outdoor <br /> 0 @ Closed 0Altered <br /> GPS Latitude m • LLIO Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) -- <br /> Q New Tire Dealer Q Auto Repair Q 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 Q Agriculture Q Shredder Q Other I 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 I Q !PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of Violation Q Extension <br /> PRC 42953-Contracts with Registered Waste Tire Haulers. <br /> Q ; Q 1 § 9 ,� Compliance Deadline <br /> Qi Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> 0 ; 014 CCR§18459.1 -Tire Program ID Number from CIWMB m m m <br /> � <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 Haule s Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilitie <br /> Q Q 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire enerators Q In Compliance - No Violations <br /> Q 1 Q 1Other: § ........... - <br /> Comments ,i t <br /> 0 A4f ft- l €- - � - -s{ <br /> J . <br /> 0 _ . r��/� ---�1�.�_►1__ �--t�-s'I--C��. _-.. +�� �' i_n _F���-�.�jai F��._ �-G�-� g <br /> Inspection Form Included: Q (( / 4 <br /> Let <br /> Comments Included: ; p -- -- - _._ ------- - P Signature <br /> Business Rep's Signature Phone Number Ins ector' Si nature _— Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: /, (* V IE�" JA,M, ,L 'E 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />