Laserfiche WebLink
ection ns Report Number <br /> Waste Tire Su & Inspection Report p p <br /> State of California ]A� �ry3Califoa ICIWMBntegrald,Waste Management Board S( ewurvey Form - Page 1 8 - 10 2 5V V ka4 <br /> Sart A- Surve BLUE OR BLACK INK PEN <br /> Business Pro Inspection Details <br /> TPID- � � I � � O � - �I / Inspection Type (Fill one) <br /> Site Suffix: L'�t Q Routine Q Re-inspection Q Referral Q Observation <br /> Local �-^ __ �- If Referral,choose referral type(Fill one) <br /> Identifier: �� „1 �r Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Address ��I - I <br /> Street <br /> Inspection DateLl d <br /> City State ZIP Code Time In I Time Out <br /> Business Rep Title O AM 1 O AM <br /> !�, O PM O PM e-"N <br /> ��C l I <br /> Operational p Status Tire Type yp Business Role Storage Type <br /> O <br /> (Fill one only) (Fill all that apply)i (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger Q Generator Q Outdoor <br /> tj Q Closed Q Altered <br /> GP$ Latitude Q Hauler Q Indoor <br /> Q Inactive Q Truck <br /> Longitude — LLL - I I if--, <br /> I ( Q Planned Q OTR" Q End-Use Q container,.' <br /> BusinessType (Fill"all hat app <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 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 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 Date <br /> M / M m <br /> Q Q 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/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 Q In Compliance - No Violations <br /> Q Q Other: § <br /> Comments <br /> t <br /> Inspection Form Included: O <br /> Comments Included: Q ----- J <br /> Business Rep's Signature Phone Number Ins 1IRter er <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X E XJ A, MIF 1 L I E1 1112131 6'1E)81 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />