Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number ■ <br /> State CIWMB California I 1 - 114 3 9 5 2 <br /> ratedW (New04/04) 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 Type (Fill one) � <br /> Site Suffix: ( ® Routine Q Re-inspection Q Referral Q Observation <br /> Local I / I_ If Referral,choose referral type(Fill one) <br /> Identifier: San �� n `OI�I{�T Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Co C o n AAAo ��v�� �r o1�U.c.,�S <br /> Physical Address <br /> 1 oa°t - <br /> j Inspection Date <br /> , GA <br /> Loi �5��u v lJ <br /> Time In Time Out <br /> Business R�e�pt rn r� Title VILL0 fptC- O AM O 0 AM <br /> e `►t PM ® PM <br /> - <br /> -- - - -- - -- -- - — Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) ,ry (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger 4l Generator Q Outdoor <br /> O 0 Closed Q Altered A <br /> GPS Latitude Q Hauler Q Indoor <br /> Q Inactive Q 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 <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> ,- <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q - 'i Q Notice Of Violation Q Extension <br /> 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 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 (9 In Compliance - No Violations <br /> Q Q Other: § <br /> Comments n , ; <br /> No vAa�,Ions c Suan _ -_ <br /> Inspection Form Included: �O�_3� r3 ��� ,I•��_ I_7i <br /> Comments Included: - - - l` <br /> Bu ss Rep' ature Phone Number Insp or's Signature__ Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: yi �/ P 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />