Laserfiche WebLink
073130401716 <br />Waste .Tire Survey & Inspection Report'... Inspection Report Number. <br />State of r CfWM1811IN— Survey Form-Page1: 1 6 1 073586 <br />CIWMB 181 (New nage Y <br />Calllomla Integrated Waste Management Boats - <br />Part A - Survey <br />BLUE OR BLACK INK PEN <br />Business Profile <br />Inspection Details <br />TPID- <br />Site Suffix: <br />/ <br />� <br />� <br />� <br />�� <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />_ <br />b <br />/ <br />Inspection Type (Fill one)` <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />I I <br />I I <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred I CIWMB Enforcement <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />I® Routine Q Re -inspection Q Referral Q Observation <br />Local <br />/ <br />Q <br />If Referral, choose referral type (Fill one). <br />Identifier: <br />CD 0.�.Lt y� f _ - , _ _ <br />`�-+�wKvY <br />Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br />Business or Facility <br />Inspected By Inspector <br />-Name /1� , <br />I CC -L i �.G.—C—1^,-pl— <br />Physical Address <br />[�R- / O <br />�a_q-1�-5.-�- <br />Street <br />Inspection Date <br />I 5�-,.0 c� I �z 15' <br />City State ZIP Code <br />Business Rep Title <br />Time In <br />Time Out <br />O AM Q AM <br />- -- L A <br />S.Q u_ Plsf,�t �ce�� <br />A PM m ®PM <br />Operational Status <br />Tire -Type <br />Business Role <br />Storage Type <br />Tire Count (Whole/PTE), <br />(Fill one only) <br />(Fill all that apply) <br />(Fill all that apply) <br />(Fill all that apply) <br />® Active <br />® Passenger <br />0 Generator <br />® Outdoor <br />l <br />O <br />Q Closed <br />Q Altered <br />GPS ,Latitude <br />W <br />,Ll <br />Q Hauler <br />Q Indoor <br />Longitude <br />O <br />Q Inactive <br />Q Truck <br />Q End <br />Q Container <br />-—I <br />Q Planned <br />Q OTR <br />-Use <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 <br />Q- <br />PRC § 42951 -Waste Tire Hauler Registration and Transport of Tires <br />— ..— -- <br />Q <br />PRC § 42953 - Contracts with Registered Waste Tire Haulers. <br />Compliance Deadline <br />Q <br />PRC § 42956 - Registration/Decal in Vehicle <br />Q <br />14 CCR § 18459 - Responsible Entities Complying with Manifesting Requirements <br />Date m / m <br />Q <br />14 CCR § 18459.1 - Tire Program ID Number from CIWMB <br />Q <br />14 CCR § 18459.2.1 - Submittal of Comprehensive Trip Logs within 90 days <br />(Required for NOV or EXT) <br />Q <br />14 CCR § 18459.3 - Retention of Comprehensive Trip Logs for 3 years <br />Q <br />14 CCR § 18460.2 - Manifest System Requirements for Registered Waste Tire Haulers <br />Q Referred I CIWMB Enforcement <br />Q <br />14 CCR § 18461 - Manifest System Requirements for Waste Tire End -Use Facilities <br />_ <br />® In Compliance No Violations <br />Q <br />14 CCR § 18462 - Manifest System Requirements for Tire Dealers or Waste Tire Generators <br />Q <br />Other: § <br />Comments <br />J—L�V1S�'itCt�� �lc�`ktA-0S--Gtr t/`�GS---�iWO-liW�l�.1•L <br />n <br />C12f1L��F+��t+- <br />_qc-r'_utG�l�Va ftY�t o-6Srs�4d/�1 - f/�V�irt(�,/+o71-L. <br />ction Form Included: U <br />Comments Included: <br />■ INSTRUCTIONS ON BACK Correct: ( <br />White Copy CIWMB <br />Yellow Copy: Operator <br />Inspector's Signature <br />ExaMP l E a.zs <br />Pink Copy: LEA <br />62081 <br />® ■ <br />