Laserfiche WebLink
Waste Tire SAW & Inspection Report Ispection Report Number <br /> State CIWMB California 1 114 0 8 81 <br /> California Int gr ed Wast 181 eManagement Board Sw 04104) urvey Form - Page 1 <br /> Part A- Survey _ BLUE OR BLACK I OPEN <br /> Business Profile Inspection Details <br /> TPID- LIQ,I r I ` - O Inspection Type (Fill one) <br /> Site Suffix: J (G' 0 Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �yru, 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name T Inspected By Inspector <br /> Physical Add ess /� 1 o <br /> SCA -1��UG <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ` �y 0 ®AM % 0 ® AM <br /> V 0 P r 0 P <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 /> 0 Active 0 Passenger ®Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude Q Hauler ® Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned ® OTR 0 End-Use I 0 Container <br /> Business Type (Fill all that apply) tti <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 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 /> 0 Notice Of Violation 0 Extension <br /> 0 0 PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CIWMB Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities A <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> Q 1 0 Other: § <br /> Comments <br /> -rilJ4117- A,11��Ieal-.I <br /> Inspection Form Included: 0 <br /> Comments Included. it - -- - �- , <br /> Business Reps Signature Ph a Number nspector's Signet a Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X ,. i X A VTEI 111213 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink VA <br />