Laserfiche WebLink
i 3 Waste Tire Suzy & Inspection Report tlnspection Report Number <br /> State of California <br /> CIWMB 181e ) Survey Form - Page 1 I 1 - 1143650 <br /> California Integrated WaststManagement <br /> Waste Management Board <br /> art A-Survey__ - --- - ----__ -- --- --__ ----- -- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- - � Inspection Type (Fill one) <br /> Site Suffix: � QRoutine 0Re-ins Re-inspection <br /> Q Referral Q Observation <br /> Local �� If Referral,choose referral type(Fill one) <br /> Identifier: n Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected B <br /> P Y Inspector <br /> Physic ddress 39 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title ) 0 AM <br /> y� <br /> t QPM C� 62 V 0 AM <br /> ® PM <br /> l 6�mzol ���y - <br /> -- - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) 7 <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � S <br /> 0 Active Q Passenger ® Generator ® Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler ®Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned 40 OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <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 ® Other �✓��}� •p ,��� `e�� 7 <br /> Part B-Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENF—OR—CECMENT 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 1:11 / 11-1 <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/CIWMB Enforcement <br /> Q O 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 Q Other: § <br /> Comments ��^^ <br /> Inspection Form Included: Q <br /> Comments Included: ® *AP Business Rep's Signatur Phone Number ature Phone Number <br /> INSTRUCTIONS ON BACK Correct_ Incorrect I �/ t L 1� 62081 <br /> ■ <br /> y:L <br /> White Copy:CIWMB Yellow Copy:Operator Pink C ■ <br />