Laserfiche WebLink
Waste Tire Su k-y & Inspection Report Inspection Report Number <br /> State of California <br /> CIWMB 181( e ) Survey Form - Page 1 I 1 - 1141232 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey b BLUE OR BLACK INK PEN <br /> Business Profile 'Inspection Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: t �. � � <br /> ,7 Q Routine Q Re-inspection Q Referral 0 Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: �, 1tiC� v�Y� lC.t r t LI O CHP Q CIWMB Q Complaint O Educational Visit O Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> Inspection Date <br /> Sfa!e ZIP 0(-,,de Time In Time Out <br /> Business Rep Title O AM i Q AM <br /> Q PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Ire Count(Whole/PTE) - �i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 1 O Active O Passenger Q Generator Q Outdoor <br /> O Q Closed Q Altered <br /> Q Hauler Q Indoor <br /> j <br /> GP$ Latitude �� <br /> Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet 0 Government 0 Retreader Q Dismantler 0 Tire Derived Fuel <br /> Q Used Tire Dealer 0 Auto Body 0 Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder @ Other I PIt" r �(y f <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation O Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date <br /> O O 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> O O 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> O O 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> O O 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities _ <br /> O 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> O 0 Other: § <br /> Comments <br /> rkLA, hi 16 !)1S)eC-/-);6-1 Ce( iIE L.i + -flute C'� JL tC1 ii(-- %�7t <br /> -trlc°ice-► -- <br /> A( c- ; 3 / : / <br /> Inspection Form Included: Q' <br /> Comments Included: Q - <br /> Business Rep's Signature Phone Number Inspector's'Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:0 Incorrect: X jl�, E j1j2 3 <br /> 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />