Laserfiche WebLink
Waste Tire Survey. & Inspection. Report Inspection Report Number . <br /> ' s"�'"alffomia1'New Survey Form - Page 1 1 6 - 1 0 0 6 7 3 6 <br /> CIWMB 1811New OQO4J <br /> Callfomle MtegraNd Waste Management Board - <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- inspection Q 1 Inspection Type (Fill one) <br /> Site Suffix: ` ` ` I*Routine 0 Re-Inspection 0 Referral. 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: S UAA, ,E �� �iJµ��'J 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> S�oL W�b� 0- 1 P I Z I Inspection Date <br /> Time In Time Out <br /> Business Rep Title a AM0 AM <br /> apt 1 ` 0 PM I Z D 0 PM <br /> 0.h V' � \' Operational Status Tire Type Business Role Storage Type: <br /> Tire Count(Whole/PTE) r (Fill one only) (Fill all that apply) (FH all that apply) (Fill all that apply) <br /> r ' w 0 Active 0 Passenger 0 Generator 0 Outdoor <br /> O 0 Closed 0 Altered <br /> GPS Latitude 0 Hauler ®Indoor <br /> O 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> ®New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body ®car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956.-Registration/Decal in Vehicle <br /> 0 0 14 CCR§16459 -Responsible Entities Complying.with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 Other. § <br /> CommentstN OA.ttA.,5 S rb"v <br /> _45_ ww�.tv�9 VAOM mks_.. _ �-c. <br /> WANtw�c�c�_W�ess <br /> Inspection Form Included: <br /> Comments Included:Q <br /> B s rg a Phone Number in actor's Signature Phone Number <br /> NINE - <br /> INSTRUCTIONS ON BACK X F L E1 j 62081 <br /> ■ While Copy.CIWMB Yellow Copy.Operator Pink Copy.LEA ® ■ <br /> 0529204.0103 <br />