Laserfiche WebLink
% I <br /> Waste Tire Survey & Inspection Report Inspection Report Number <br /> Stateof edWafornla Survey Form - Page 1 1 2 - 100809 2 <br /> cIWM9 is1(New 04104) <br /> California Integrated waste Management Board <br /> Part A-,Survey BLUE OR BLACK INK PEN <br /> Business Profile — - I Inspection Details <br /> TPID- � b J, _ t Inspection Type (Fill one) <br /> Site Suffix: "t <br /> ® Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> V <br /> 1_ q r Inspection Date <br /> ` �oLl CIA- ` ' Time In Time Out <br /> Business Rep Title - O AM Q AM <br /> O PM O PM <br /> Operational Status Tire Type Business RoleStorage Type <br /> Tire Count(Whole/PTE} �.. (Fill one only) (Fill all that apply). (Fill all that apply) (Fill all that apply) <br /> r ; Active Passenger Generator ®Outdoor <br /> 0 Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 O Inactive Q Truck <br /> Longitude — Q Planned Q OTR O End-Use Q Container <br /> f Business T I <br /> ype (Fill all that apply) I <br /> Q New Tire Dealer 9 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body © 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 FacilityE.NF�iR3 ME T TA '�J <br /> V-11 : _ HAU NQ'ANO M lim REQUIREMENTS <br /> O O O Notiao 4t v pltlt ir) <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires ` <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. COmEtll>Altca1�1t�#Ihe <br /> Q O PRC§42956-Registration/Decal in Vehicle <br /> Q 1 Q 14 CCR§18459 Responsible Entities Complying with Manifesting Requirements 5 <br /> Date j <br /> O O 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB //tea <br /> /� . <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years ".7': <br /> O : O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers * <br /> Ra <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O . O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators $ v ''y �%�/� MR <br /> O O Other: <br /> Comments <br /> Inspection Form Included: Q J <br /> Comments Included: QI—• --- — - �? l <br /> i I Business ep's Signature Phone Number inspectors nature Phone Number <br /> r .:•:;-..._. 'J' 62081 <br /> INSTRUCTIONS ON BACK Q : '1pii �/t E X A� P L 2 3 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA ® ■ <br />