Laserfiche WebLink
07312040454 <br /> Waste Tire Survey &Inspection Report Inspection Report NumberState ■ <br /> CTWINI fCalfomla Survey Form - Page 1 1 6 - 10 7 3 5 2:0:1 <br /> CIWMB tet stew nage - y <br /> Callfomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Z O Inspection Type (Fill one) <br /> Site Suffix: / 3 1 i Y 0 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: bGt�,v,n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ' Inspected By Inspector <br /> - <br /> Physical AddFess <br /> L_. <br /> Street <br /> Inspection Date <br /> U <br /> City SSt ZIP Code I Time In Time Out <br /> Business Rep Title' <br /> :F1 lm'm ®PM <br /> Operational Status Tire Type Business-Role Storage Type <br /> Tire Count(Whole/PTE) i (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> t, 0 Active Q Passenger 0 Generator ®Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude 11-14 '.1-LI_ Q Hauler Q Indoor <br /> O Q Inactive to Truck <br /> Longitude _ I I I lv Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) III L <br /> Q New Tire Dealer Q Auto Repair ®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 /> I� <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I I <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of violation Q Extension <br /> Q Q 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 <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 1 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 ®In Compliance - No Violations <br /> '© Q Other: § <br /> Comments <br /> J- <br /> - <br /> Inspection Form Included:Q <br /> Comments Included:Q <br /> u ss"Slt�re <br /> ' Phone Number Inspector s Signature one Number <br /> 62081 <br /> INSTRUCTIONS ON BACKIncorrect: X A M P L E 1 i2 3WhitYellow Copy.Operator Pink Copy LEA ® ■ <br />