Laserfiche WebLink
Waste Tire Survey & Inspection Report Inspection Report Number <br /> Slate of California <br /> Cgrated Waste <br /> nage Survey Form - Page 1 I Z - 1 0 0 8 0 8 4 <br /> Callfomta Integrated Waste Management Board <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile I Inspectlon Details <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 62 ,7 Z - 1 e Routine Q Re-inspection Q Referral Q Observation <br /> i <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �C7Ct�J lntrY� �p -�_ l Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name f� r Inspected By Inspector <br /> Physical Address ar /���• <br /> Inspection Date Q <br /> � <br /> Time In Time Out <br /> Business Rep Title 0 AM 0 AM <br /> ' 0 PM 0 PM <br /> Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> f o o Active 0 Passenger ®Generator 0 Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor , <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> I <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 /> Q 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 _ENFORG_EMENT STATUS. <br /> V I A I HAULING AND MAMFEST REQUIREMENTS <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires Q Notice Of ylchftlpn Q�xtenefQtt <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance I044llrt41 <br /> Q Q PRC§42956-Registration/Decal in Vehicle m m <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Data <br /> 010 14 CCR§18459.1 (a)(b)(c)-Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days (RegetfiedfrhlC9V <br /> 14 CCR 18459.3-Retention of Manifest Forms and Tire Tri Logs for 3 ears <br /> Q Q § P 9 Y <br /> Q O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 01 erirthnd tIlll <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> Other: § ,✓1 / `.>.GrE... <br /> 6 <br /> Comments 4- .>; <br /> /J Ov�Sf '.d ` `-' Z <br /> 1 <br /> Y "1QN1'l*/n l ` n <br /> Inspection Form Included: Q <br /> i Comments Included: mus Q�J� �J �! "OS L'�-Q�i�j <br /> ass Rep's Signature Phone Number s Ig atur Phone Number <br /> --IA— <br /> INSTRUCTIONS ON BACK Cot b10 Inco ot: ( } M J M P L E ��� 62ot31 <br /> Whitecap .CIWM Yellow Copy:Operator Pink Copy:LEA <br />