Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> CIWMB <br /> 181(New 04104) Survey Form Page 1 I 1 - 114 3 5 4 0 <br /> California Integrated Waste Management Board - - <br /> Part A- Survey __. <br /> - -_ BLUE OR BLACK INK PE <br /> Business Profile Inspection Details <br /> TPID- � � Inspection Type (Fill one) <br /> �Site Suffix: 4%Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SOn a0tTA:n ((7U n� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> A BCCA SGlSS(�r L1 <br /> Physical Address <br /> 2)q Lo p� �h CfC4L — <br /> �O Inspection Date "7 Q <br /> Time In Time Out <br /> Business Rep Title C O AM r� O AM <br /> PM � � V ® PM <br /> -- <br /> - -- - - - - - - —- -- Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> ' ® Active Q Passenger 0 Generator • Outdoor <br /> GPS <br /> Latitude O Q Closed Q Altered Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude — Q Planned OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) SCJ 0{6 <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 r I_ p <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ® `14 Other �erVi(1I,S� S4`�5� tLcPtj <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A <br /> � ;HAULING AND MANIFEST REQUIREMENTS <br /> 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 / m <br /> 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 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 <br /> in Compliance No Violations <br /> Q Q Other: § — <br /> Comments LA\\W_ <br /> Inspection Form Included: 4siinllQW <br /> Comments Included: ,?` <br /> t� <br /> eps Signature Phone Number Inspe is Signature Phone Number <br /> ! - - — ---- - <br /> E X A „;'-f z Ii L. El 11] 3 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect �� � �, ,� <br /> ■ <br /> ■ <br /> - --- - - <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />