Laserfiche WebLink
Waste Tire urvey & Inspection Report Inspection Report Number ■ <br /> State of California <br /> CIWMB <br /> 181( ew 04104) <br /> I 1 - 1143514 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> r <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: ( y C Is Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local �` _- \^- If Referral,choose referral type(Fill one) <br /> Identifier: L� L( �{'��'1Yt t!Crl/✓< 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name V <br /> Inspected By Inspector <br /> ire _ <br /> Physical Adt�re s `, 0All <br /> � /A r _,bu)c, <br /> Inspection Date 1 C) 1 <br /> ►'lC;� L'c wt QS i P Out Time In Time Out <br /> Business Rep Title O AM 0 AM <br /> • G ® PM ® 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) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Latitude 0 ® Closed 0 Altered i /V/,4 <br /> GPS 0 Hauler 0 Indoor <br /> 0 0 Inactive ® 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 0 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 ® Other <br /> live '"T�� J:�✓z�l'c� <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V j 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. Compliance Deadline <br /> 0 ! 0 PRC§42956-Registration/Decal in Vehicle <br /> 00 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / 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 LL <br /> Inspection Form Included: 01 <br /> Comments Included: "ture <br /> Business Rep's Signatu a Phone Number In to ' Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct * Incorrect: t I IE � <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink py: <br />