Laserfiche WebLink
Waste Tire Sup .6, & Inspection Reporto*pection Report Number <br /> State CIWMB California I - 114 0 7 31 <br /> grated Waste <br /> eManage) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A-Survey__- BLUE OR BLACK INK PEN <br /> -- --- - - <br /> Business Profile Inspection Details - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: �5 5 © e Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: :�I_;Ly-\ Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address l <br /> Inspection Date k-)� <br /> r'l(_Iv� �. ��� � � <br /> Time In Time Out <br /> Business Rep Title 3 �*� 0 AM ] �. AM <br /> 0 PM 1 C 0 PM <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 /> Q-Active—- *-Passeng o�Generator- Outd - d <br /> - O 0 Closed Q Altered /Vl,4 <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude Q End-Use 1 Q Container0 Planned 0 OTR <br /> Business Type (Fill all that apply) - - <br /> Q New Tire Dealer p 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 la Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS l <br /> --- --- -- --- - - — -- ...-- -- - ..... <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 / 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 O <br /> 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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q Q ® In Compliance - No Violations <br /> Q Q Other: § rr � rr -- <br /> Comments A.- t'ne ,1�sDe b✓t C°'t5Y1f�tJGTcC� !� (�c^� fc <br /> J Cmcems 10 k -1 -6 <br /> Inspection FormIncluded: Q <br /> Comments Included: Q ����� �� -- -- <br /> Business Rep's SlgnaturA Phone Number I r' ature_— Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: X ! <br />