Laserfiche WebLink
Waste Tire Shy & Inspection Repore Inspection Report Number <br /> State of California <br /> CWMB 1(New04/04) Survey Form s Page 1 11 .114117 0 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �� ���L't_...,. s � Q Routine Q Re inspection Q Referral Q Observation <br /> L_i <br /> Localj If Referral,choose referral type(Fill one) <br /> Identifier: v_J11 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> ILI <br /> Physical Addressg�i t f <br /> 11 1�el I <br /> ...... .. _. _......_.: ..._._...... 1.0:� �. .1~. _...... _ <br /> i <br /> Inspection Date <br /> Time InTime Out <br /> Business Rep Title i (DAM AM <br /> }} tJ\ I 0F. � �� ' �� � • QPM <br /> _ _.............. ..... t.... C,,.1.:l�.._.._...... <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 /> t Q Active O Passenger Q Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q indoor <br /> �_......--...-..-•� Q Inactive 0 Truck <br /> Longitude Q End-Use Q Container <br /> 9 Q Planned 0 OTR <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 ® 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 /> Q § - a - Q Notice Of Violation Q Extension <br /> 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 Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date m / 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 (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 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 Q In Compliance- No Violations <br /> Q Q Other: § <br /> Comments <br /> 1 <br /> i <br /> i <br /> Inspection Form Included: Q <br /> Comments Included: Q <br /> Business Rep's Signature Phone Dumber inspector's Signature Phone Number <br /> --- 62081 <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: �iMt ' (r <br /> 0 White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />