Laserfiche WebLink
Waste Tire Sur& Inspection Report • ction Report Number <br /> State of California Survey Form - Page 1 11 - 1127527 <br /> CIWMB 181(New a04) ry <br /> California Integrated Waste Management Board {�• <br /> Part A-Survey BLUE OR BLACK _INK PEN_ <br /> Business Profile Inspection Details <br /> I! TPID- �a � � ;Inspection Type (Fill one) <br /> Site Suffix: Ll /U <br /> ® Routine QRe-ins Re-inspection <br /> Q Referral Q Observation <br /> Local <br /> Identifier. �`n ^� j If Referral,choose referral type(Fill one) <br /> % ► l �u1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected B <br /> p y Inspector <br /> Physical Address <br /> Inspection Date <br /> / Q / <br /> Time In ! Time Out `.J <br /> Business Rep Title Q AM Q AM <br /> ' L ® PM lJ ®PM <br /> - -- Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count (Whole/PTE) 501 <br /> _ ®Active Q Passenger ® Generator ® Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> O Q Inactive ® Truck <br /> Longitude - Q Planned ® OTR ® End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> QNew Tire Dealer Q Auto Repair Q Trucking Fleet Q Government ® 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> - --- - -- <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q 01 <br /> 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> Q ' Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q � 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> (Required for NOV or EXT) <br /> O0 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance No Violations <br /> Q Q Other: § <br /> Comments <br /> Al1)1 Ld <br /> Inspection Form Included: QiG- <br /> comments Included: Q - <br /> Business Rep's bgnure oneNumber In tor' Si nature Phone Number <br /> - _ 62081 <br /> INSTRUCTIONS ON BACK Cor ncorrect: X !� �/ 1XX1 M, P 1- E 3White Copy: Yellow Copy:Operator Pink Copy:LEA <br />