Laserfiche WebLink
Waste Tire Su, - ey & Inspection Report Inspection Report Number <br /> CIWMB 81'fornia <br /> (New 04/04) SurVe Form - Paae 1 I 1 - 1141010 <br /> California Integrated Waste Management Board Y g <br /> Part A-Survey -_ - _ BLUE OR BLACK INK PEN <br /> FBusiness Profile Inspection Details <br /> TPID- o r A a - I Inspection Type (Fill one) <br /> Site Suffix: 7 S O ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SQA JQ(J� ulll cou Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> T�_ (0\(_-, _�o y �IoC, 1 - d <br /> Physical Address E WAo <br /> 151() 1 Inspection Date O o f Q <br /> 1 J "� Time In Time Out <br /> Business Rep Title � � O � P � � D 0 <br /> M 0 AM <br /> nt <br /> - - e f f 11 Cem��� 0 u� M PM- <br /> ----- - -- --- Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) I (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active Passenger ® Generator Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive Q Truck <br /> Longitude - Q End Use Q Container <br /> Q Planned OTR <br /> i <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 15,61ef V ll 04 -SOWd SuI <br /> �S <br /> Part <br /> Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility [-ENFORCEMENT STATUS <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 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 ® In Compliance - No Violations <br /> 010 Other: § <br /> Comments 11�1 \ 1 t <br /> A� <br /> Inspection Form Included. ---- ("` <br /> Comments Included: <br /> Business Rep's Signat Phone Number Inspec 's Signature one Number <br /> INSTRUCTIONS ON BACK Correct:I* Incorrect: J A A 1 w 1 62081 <br /> ■ White Copy.CIWMB Yellow Copy:Operator Pink Cop :LE ® . <br />