Laserfiche WebLink
Waste Tire SuSy & Inspection Report inspection Report Number ■ <br /> State of California <br /> CIWMB Survey Form - Page 1 1 7 - 1 0 1� � { <br /> 30 <br /> California Integrated Waste Management Board ------ ------ --- - --- --- <br /> �art A Survey BLUE OR BLACK INK PEN <br /> r�"s <br /> r 'E <br /> TPID- FIn <br /> spection Type (Fill one) <br /> Site Suffix: ff A� J j / ail # 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 By Inspector <br /> _ <br /> Physical Address y <br /> Street <br /> Inspection Date <br /> ^"w_— State ZtP Code Time In Time Out o <br /> Business Rep Title L�L_ � C)AM O AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> N; (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Active 0 Passenger 0 Generator 0 Outdoor <br /> GPS - � �D Closed Altered O O <br /> Latitude /I��L� Hauler Indoor <br /> Longitude – �r- <br /> O Inactive 0 Truck <br /> 9 Planned 0 OTR End Use 0 Container <br /> f <br /> Business"type (Fill all that apply) <br /> 0 New Tire Dealer Q Auto Repair 0 Trucking Fleet 0 Governme t 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder q 0 Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation � Extension <br /> O O <br /> 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 ® 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <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 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators 0 In Compliance - No Violations <br /> 0 0 (Other: § - <br /> r <br /> Comments I <br /> _ .t✓}/.G-T":='rte J: rdT'. '�.. ' <br /> 1 <br /> Inspect"ion Form Included. (�' <br /> Comments Included: - <br /> 0 Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* incorrect: 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />