Laserfiche WebLink
Waste Tire S*ey & Inspection Repo# Inspection Report Number <br /> State California <br /> CSurvey Form Page 9 1 3 - 1 0 2 8 4 9 <br /> IWM5WMB 181 New 04104) <br /> Callfornla Integrated Waste Management Board <br /> Part A- SurvM _ BLUE OR R BLACK_INK PEN <br /> Business Profile Inspection Details <br /> Business <br /> . /� Inspection Type (Fill one) <br /> Site Suffix: ' a ( I V 0 Routine Q Re-inspection Q Referral Q Observation <br /> LocalIf Referral,choose referral type(Fill one) <br /> Identifier: 0� MIK C�L1�1 - O CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name _'Uo <br /> inspected By Inspector <br /> Physical Address y 6 J_euuu. R <br /> of q 6- vv. gob,, 1 )100ct b �r <br /> ,��-o _ <br /> Inspection Date I `'2 I <br /> C�.�`1 SSD <br /> Time In Time Out <br /> Business Rep Title O AM i O AM <br /> O PM O PM <br /> l,(5-h4'1 __ (obfV1S0tj — – <br /> J Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) f O I(Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Passenger ® Generator Outdoor <br /> Latitude <br /> D Q Closed Q Altered <br /> GPS O Hauler Q Indoor <br /> t) J 0 Inactive Q Truck <br /> Longitude - O End-Use Q Container <br /> , o Planned 0 OTR <br /> Business Type (Fill all that apply) <br /> ® New Tire Dealer Q 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 Deafer, Generator, Hauler and End-Use Facility ' %l <br /> 00 ' <br /> PRC§42951 -Waste The Hauler Registration and Transport of Tires t✓'�fa '� <br /> O 0 _ i�/%' <br /> PRC§42953 Contracts with Registered Waste Tire Haulers. � fix% �y,�ri, � •/r/rte <br /> O 0 <br /> PRC§42956 Registration/Decal in Vehicle !1i�- s .;•• �.., ;fir// <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 00 0 ;: y <br /> 14 CCR§18459,1 (a)(b) (c)-Tire Program ID Number from ClVUMB <br /> 14 CCR 18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 days .///�/ ''/- <br /> 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 1 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 /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators % W' ' <br /> O O Other: § / iVi < a <br /> Comments — <br /> �is-Z ����� ��c��sfi_ a cea`1 ai fe <br /> u�Dri - igSpeclib ,r _1110 V►0 l0y e n,s , <br /> Inspection Form Included: <br /> Comments Includ d: 0 - — Ap <br /> B nes ep SignaturePhone Number AtI -1gn_ature� Phone Number <br /> W <br /> 62081 <br /> INSTRUCTION N BACK X TIMI lr f <br /> While Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />