Laserfiche WebLink
{ - Waste Tire Sul- ,y & Inspection Report inspection Report Number <br /> !li <br /> 7 State of California <br /> CIWMI3 <br /> 04/04) <br /> I - 1140957 <br /> California Int grat d'Was eeManagement Board Survey Form - Page 1 <br /> Part A- Survey - BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- / S / - O ' Inspection Type (Fill one) <br /> Site Suffix: ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: '� 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected B <br /> P y Inspector <br /> - N,��i� <br /> Physical Address - < (� I /��� �Oe.✓{�Y.u`� <br /> Inspection Date ` C ) <br /> CA >> !Z <br /> Time In Time Out <br /> Business Rep Title D / O AM 0 AM <br /> ` ® PM G 2 I 5 8 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) r- (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> Qp O 0 Closed 0 Altered <br /> Latitude 0 Hauler - <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <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 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 j A I HAULING AND MANIFEST REQUIREMENTS <br /> -- - -- ----- -- ---- ---- -- - 0 Notice Of Violation 0 Extension j <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 m / m / m <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 NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years j <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 • 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No Violations 1 <br /> 0 j 0 1 Other: § <br /> Comments ,f/�� � <br /> 5; A"kA- Q_ .dAJ <br /> Inspection Form Included: 0' <br /> Comments Included: ® a z3 <br /> Business Rep's Signature Phone Number Inspector's SignmVe Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X A P f 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Co <br />