Laserfiche WebLink
Waste Tire Su .1y & Inspection Report Inspection Report Number ■ <br /> State of California I 1 1140939 <br /> "F rnia CIWMa 101(New nage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-_Survey BLUE OR BLACK INK PEN <br /> I Business Profile J Inspection Details <br /> TPID- ' � _` � � � _ � Inspection Type (Fill one) <br /> Site Suffix: J` 5 ' ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Ew 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name -- <br /> /I Inspected By Inspector <br /> Physical Address <br /> Inspection Date / c) <br /> CA � 33a <br /> Time In Time Out <br /> Business Rep Title / rrll O AM O AM <br /> 0 <br /> ))-- 0 ' V * PM Q G ® PM <br /> -- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) p <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ,2 f <br /> 0 Active 0 Passenger ® Generator ® Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude – 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader ® Dismantler 0 Tire Derived Fuel <br /> 0 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 ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> -- _ ____._---- _ ..�.. _.... ____._._----------_--_-- __ 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date Fl] / M / � <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days ! (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive 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 <br /> Inspection Form Included: 01 <br /> Comments Included: ®IIx <br /> '— y t7 — �Slgnature <br /> Business Rep's Signature Phone Number nspePhone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X �. V l X A Ak <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy LE <br />