Laserfiche WebLink
Waste Tire Sui y & Inspection Report ,spection Report Number <br /> "' State B California I 1 - 1140988 <br /> Cgrated Waste <br /> eManag) Survey Form - Page 1 <br /> California Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection <br /> r 3 Inspection Type (Fill one) <br /> Site Suffix: T ` ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: SCL4n70 VN_, (^ ,,,`^� Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> mss"� _ —-- - -- — <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> rL_J <br /> Inspection Date i o C) , O <br /> Time In Time Out <br /> Business Rep Title *AM * AM <br /> � ` / / � `� QPM <br /> Dm;nie Vq � iufCt ID QPM t Cl 0 - --- <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) 1 (Fill all that apply) <br /> > > to ® Active Q Passenger ! ® Generator Q Outdoor <br /> D Q Closed Q Altered /(/` <br /> - �S Latitude Q-Hauler Q-rdeor <br /> O Q Inactive ®Truck <br /> Longitude - Q Planned ® OTR Q End-Use Q Container <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 C"k,I FruGQ SSi VN.5 <br /> Part B - 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 /> 0 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 C (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 /> al Q Other: § <br /> Comments <br /> avi 4W 1,i(U"j �5 W4cC yxo,{ <br /> Inspectioned: <br /> Comments Included: Q <br /> c u ed: - ---- - - -- -- - - - - <br /> Q'Busin ss Rep's Signatureb4kone Number spector' Signature Phone Number <br /> - - - - Nu <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X l F�7 IA` � P � I �� 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink py: <br />