Laserfiche WebLink
i Waste Tire Survey & Inspection Report Inspection Report Number <br /> State ofCalifornia Survey Form Page 7 1 9 0 0 6 3 3 5 <br /> C1WN6181(New 04104) � <br /> California Integrated Waste Management Board <br /> Part A,_Su iyey _ _ _ _ BLUE OR BLACK INK PEN <br /> Business Profile 4 _-�Inspection Details _ _- __j <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: J 3 7 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalL If Referral,choose referral type(Fill one) <br /> Identifier: �C,t� L,lr. Q CHP Q CIWMB O Complaint Q Educational Visit Q Other <br /> Business or Facility Name ''"" ��,,.. <br /> Inspected By Inspector <br /> Physical Address 3 9' <br /> Avg- - - <br /> 7 Inspection Date <br /> 01537 Time In Time Out <br /> Business Rep Title O AM Q AM <br /> ( �? Q PM Q PM <br /> "'fever C..TO►v� '� ��4~�qt,� <br /> — — -- — - J — Operational Status Tire Type Business Role f Storage Type l <br /> Tire Count(Whole/PTE) <br /> if .(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> � � <br /> 0 Active 0 Passenger ® Generator 0 Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - - - Q Planned i Q OTR — O End-Use I Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> O 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 J <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility <br /> <:cr+;s:�i/?lsH:.;fj-�'� %-;ii-^� '' . <br /> %'i ?'f ." I/G' /: / '/i /iii/a-. � ��' ��'•/ ... , - ,.. .--.,_:'^, _ -. /iii/i`o✓;,i//k%�',/,'i '�x'�%.x:... �.. <br /> O O PRC§42951-Waste Tire Hauler Registration and Transport of Tires l /� <br /> O O � "INN <br /> PRC§42953-Contracts with Registered Waste Tire Haulers. s i�•i- i'/ j,/�i <br /> PRC§42956-Registration/Decal in Vehicle <br /> O O 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements f % <br /> Q O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> Q O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> 01 O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Q 1 Q Other: § <br /> Comments / <br /> Na <br /> �if'�Ei�n1�� - - wY,ttG�1�¢.•-e - /�f��Cr'/ ��i�y,� /} ' <br /> I <br /> ( <br /> 47 - <br /> Inspection Form Included: Q <br /> Comments Included: Q -- - - - - — -- — C� <br /> Business 'a Sig ture Phone Number In Gee Sig re Phone Number <br /> 62081 <br /> INSTRUCTIONS ON BACKNIFE A'MIPILIEI IIIZ13 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />