Laserfiche WebLink
Waste Tire Survey �v �ns pectdon Report Inspection Report Number ■ <br /> II ll <br /> State of California p �r�Qn �prI 11 �I 1143755 <br /> CIWMB181(New04104) Su eV, FO0 n o ,age 1 <br /> California Integrated Waste Management Board �1 <br /> BLUE OR BLACK INK PEN <br /> Part A-Survey <br /> Business Profile Inspection Details <br /> TPID- Q 9 5 0 1 I _ I Inspection Type (Fill one) <br /> Site Suffix: V Q Routine Q Re-inspection ® Referral Q Observation <br /> Local � t If Referral,choose referral type(Fill one) <br /> Identifier: Jo ('�5 C � Q CHP Q CIWMB Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> r� Inspection Date � � ® <br /> Time In Time Out <br /> Business Rep Title 0 AM r� O AM <br /> I <br /> ° 1 ® ® PM d O QPM <br /> �Gs�os 1 6-'w rfe, ®wneS - <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> q (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all.that apply) <br /> s ' 0 Active Q Passenger ® Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude 41 Hauler Q Indoor <br /> O Q Inactive 0 Truck <br /> Longitude Q End-Use Q Container <br /> Q Planned Q OTR <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 /> 4k Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station ®Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS _ <br /> V I 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 / m <br /> Q O 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 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> -- 6��`�� <br /> v Lon own. <br /> W'n %(4 mAo r <br /> Inspection Form Included: • , <br /> Comments Included: 4f�-• - - - - - ��„�!/� --- —�� � dv_L�-tL%_7!_11' 0— <br /> Business _g r_l�~ Phone Number _Inspe is Signature Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK GoteC*t: Incorrect: r r I® White Cop Yellow Copy:Operator PinVC_ ® ■ <br />