Laserfiche WebLink
Inspection Report Number <br /> Waste Tire Survey & Inspection Report ■ <br /> State of California <br /> CIWMB 101(New 041041 Survey Form Page 1 C 6 - 10 2 5 6 11 <br /> California Integrated Waste Management Board <br /> Part A-Survey- <br /> BLUE OR BLACK INK PEN <br /> [IBusiness Profile Inspection Details <br /> 1. _. - <br /> TPID- Inspection Type (Fill one) <br /> Site Suffix: 13 g Z 6 d 1 O Routine ® Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fitt one) <br /> Identifier: +� � tnf't.+ t r'f� Q CNP Q CIWMB Q Complaint O Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> 1 ZC-tL-.-.. �'�r✓ `�Gt'ori _ / j <br /> Physical Address <br /> q"4-7 <br /> Inspection Date <br /> Time In Time Out <br /> Business Rep Title Q AM Q AM <br /> QPM QPM <br /> Operational Status Tire Type Business Role � Storage Type <br /> (Fill one only) (Fill all that apply) (t=ill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) f � <br /> III Active Q Passenger ®Generator ®Outdoor <br /> O Closed Altered <br /> � <br /> GPS Latitude Q Hauler Is Indoor <br /> 0 0 Inactive ®Truck <br /> Longitude — 0 Planned Q OTR ®End-Use Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> O Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> 0 Service Station Q Hauler Q Agriculture Q Shredder 0 Other ,J tr� <_ �� <br /> � - I <br /> Part B-Inspection of Waste Tire Dealer,Generator, Hauler and End-Use Facility ENFQRCEMEN7:T8TATU <br /> _ .... _ - n-Wx <br /> V A HAULING/kNQ MANIFEST REQUIREMENTS Vloftttfonitilt� E <br /> O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires i; a s, <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. Cotnpllulca 0011�lintl x <br /> O O PRC§42956-Registration/Decal in Vehicler <br /> 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Drl>ts.. ZJ (yl © ' <br /> O O 14 CCR§18459.1 (a)(b)fc)-Tire Program 1D Number from CIWMB ;c <br /> (Requlretf#or N�1�'Gf" i;� <br /> O O 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days y <br /> O O 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip logs for 3 years <br /> O ' O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0$6filf9�l Cllll4llhfl , <br /> 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> O 0 <br /> .F1 <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators � <br /> 0 Other: § <br /> Comments �✓fGI 1 i, /_ 4" <br /> 1 f <br /> c7-� +ire <br /> M 13 ( � '�I' cQR �Q rt- �.3-vS� P IK j� v -r- *rre- 55 <br /> Inspection Form Included: Q t^ o^ <br /> Comments Included: ®-G v�- QUO-575--&&695 <br /> Business Rep's ignature Phone Number Inspe or's Sign ur Phone Number. <br /> _ 62081 <br /> INSTRUCTIONS ON BACK Correct. incairlrect;. ( E X A M P L E 1 2 3 <br /> Entered - -= <br /> KQ White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br /> Q <br />