Laserfiche WebLink
® Waste Tire Sway & Inspection Report* Inspection Report Number <br /> State of California <br /> dmmr CgraMB ted , teManage Survey Form - Page 1 I - 1127647 <br /> California Integrated Waste Management Board <br /> Part A- Survey- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- I (1�j <br /> Inspection Type (Fill one) <br /> Site Suffix: j5­ f mm 0 Routine 0 Re inspection 0 Referral 0 Observation <br /> Local --T` I If Referral,choose referral type(Fill one) <br /> Identifier <br /> /r �t L1 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> per-_ <br /> Physical Address <br /> =eer i <br /> Inspection Date ILO] <br /> t Time In Time Out <br /> �a<e L Maze <br /> Business Rep Title f j 0 AM C) AM <br /> _ _ <br /> IC, 0 <br /> !' PM <br /> Ao P? <br /> T Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) <br /> "Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE).; <br /> 0 Active 0 Passenger 0 Generator 0 Outs ion' <br /> Latitudes ._.__...._r.... __�O 0 Closed D AI€ ,erg <br /> GP$ 1 0 Hauler 0 Indooi <br /> O <br /> I <br /> 0 Inactive 0 Trul,k <br /> I <br /> Longitude – I 0 End-Use 0 Container <br /> �0 Planned OTR <br /> 1 <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 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 0 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 <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 NO'✓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 <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 I Other: § <br /> Comments & c J i e <br /> Ila- <br /> IN lu 116C <br /> C- JA 61 <br /> 1 _ <br /> 6 t ��r' f'd'?d61_e <br /> V— <br /> a . . <br /> inspection Form Included: 0 <br /> Comments Included: 0 <br /> Business Rep's Signature Phone Number Inspector`s Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:® Incorrect: X p X A ,M � ��� 62oa1 <br /> ® White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />