Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> StateWMB 1181(Newew041D4)n(CaliforniaSurvey Form - Page 1 1 5 - 1 4 2 5 7 3 5 <br /> CI <br /> California Integrated Waste Management Board <br /> [Part A- Survey_ _BLUE OR BLACK IN_ K PEN <br /> IBus,Iness Profile I Inspection Details <br /> TPID- / c� I Inspection Type (Fill one) <br /> Site Suffix: ! 0 G ( ` ® Routine O Re-inspection Q Referral O Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint Q Educational Visit O Other , <br /> Business or Facility Name 1 Inspected By Inspector <br /> //�L�C <br /> Physi/ I Addr ss <br /> f_ Inspection Date <br /> � Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> Q PM O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply)1 (Fill all that apply) <br /> ® Active Q Passenger Generator ® Outdoor <br /> O Q Closed o Altered <br /> Latitude <br /> GPS O Hauler i Q Indoor <br /> O 0 Inactive Q Truck + <br /> Longitude - O Planned O OTR O End-Use Q Container <br /> Business Type (Fill all that apply) <br /> o New Tire Dealer Q Auto Repair Q Trucking Fleet O Government O Retreader O Dismantler O Tire Derived Fuel <br /> 0 Used Tire Dealer Q Auto Body Q Car Dealer Q Collection 0 Crumb Rubber <br /> Q Service Station Q Hauler 0 Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFO. NtTSYATU `y; `° f; <br /> A <br /> V MAULING AND-MANIFEST REQUIREMENTS iQ Q 'No.a f Vloietlon <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires t <br /> O i O PRC§42953-Contracts with Registered Waste Tire Haulers. ICY G07jtfi �, � ;a� <br /> PRC§42956-Registration/Decal,in Vehicle <br /> O O 14 CCR§ 18459 -Responsible Entities Complying with Manifesting Requirements <br /> O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB � ' <br /> o A <br /> O O 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (R�Q1��� W <br /> O O § -Retention oForms P Logs for 3 <br /> 14 CCR 18459.3 f Manifest Fand Tire Tri s years <br /> �- <br /> O O 14 CCR§ 18460.2-Manifest System Requirements for Registered Waste Tire Haulers °h <br /> �.. l <br /> O 1 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O <br /> 14 CCR§ 18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> O 1 Other: § ss"1•:i=r- "_. ty�_ <br /> Comments <br /> ee- <br /> Inspection Form Included: Q <br /> Comments Included: — -- <br /> Bus ess Rep's igna ure Phone umber In pecto ' .i ure Phone Number <br /> INSTRUCTIONS ON BACK F L E r 2 3 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />