Laserfiche WebLink
Waste Tire ,.urvey & Inspection Rep-,I Inspection Report NumberState of Cal <br /> ■ <br /> CIWMB 811fornia(New I04104) 1140809 <br /> California Integrated Waste Management Board Survey Form - Page 1 <br /> DartA- Survey_- - BLUE-OR BLACK INK PEN <br /> siness Profile Inspection Details <br /> tplp_ r Inspection Type (Fill one) <br /> Site Suffix: f 2� a j l ® Routine Q Re-inspection Q Referral Q Observation <br /> Local \^ If Referral,choose referral type(Fill one) <br /> Identifier: ��' m Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> Inspected By Inspector <br /> Physical Addres\� s � <br /> Kc <br /> q Inspection Date � 1 � � � � 7 <br /> S crtti'�CNS "� �1 �� Time In l Time Out ` <br /> Business Rep Title OAM �] O AM <br /> l ' 3 O PM Q ® PM <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Q Active Q Passenger ®Generator Q Outdoor <br /> O ® Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive ®Truck <br /> Longitude — Q End-Use ® Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> New Tire Dealer Q Auto Repair 0 Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> j V A HAULING AND MANIFEST REQUIREMENTS <br /> 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 i <br /> Q Q 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements Date M / M / m <br /> Q � Q j 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 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 Q Other: § <br /> Comments (' <br /> ..—pection Form Included: 01 <br /> Comments Included: -A- let-,-leo- C'-✓ =YG�i <br /> Business Rep's Signature Phone Number I p tor' nature Phone Number <br /> INSTRUCTIONS ON BACK j Correct:* incorrect l�,, YI� X A� M P ; 62081 <br /> ■ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA © ■ <br />