Laserfiche WebLink
■ ;` � Waste Tire Survey & Inspection Report inspection Report Number <br /> SCIWM1 18i(NewCaliforni , Survey Form Page 1 f 2 0 4 8 9 <br /> GIWM818t New 04104 ■ <br /> California Integrated Waste Management Board <br /> Part-A-_Survey BLUE OR BLACK INK PEN <br /> �Business_Profile_ _ Inspection Details <br /> TPJp_ ry r Inspection Type (Fill one) <br /> Site Suffix: 3 0 �i �j 7, 0 f I Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��r JQ Nrr ��I�.�•Ty Q CHP Q CIWMB ()Complaint Q Educational Visit Q Other <br /> Business or Facility Name r / Inspected By Inspector <br /> Physi al Address �� <br /> Inspection Date t> 1CS✓"7 W` �� ��� Time O'u't7 <br /> Business Rep f TitTime In TimTitle O AM Q AM <br /> 0 PM 0 PM <br /> Operational Status Tire Type ( Business Role I Storage Type <br /> The Count(Whole/PTE) 1 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 3 O D i� 0 Active Q Passenger ®Generator I Q Outdoor <br /> D Q Closed Q Altered <br /> GPS Latitude 0 Hauler I ® indoor <br /> � Q inactive •Truck <br /> Longitude .. o Planned Q OTR o End Use Q Container <br /> Business Type (Fill all that apply) <br /> Q 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 /> i <br /> Q Service Station Q Hauler Q Agriculture Q Shredder ®Other FrM, '-Lh <br /> Part B Inspection of Waste Tire Dealer Generator, Hauler and End Use Facility <br /> .%yi''�y'• :/rsY <br /> o PRC§42951 Waste Tire Hauler Registration and Transport of Tires r7l�ijt� " <br /> l vG <br /> 0 o PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> .� <br /> C7 Q PRC§42956-Registration/Decal in Vehicle s R <br /> o 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements �- b S <br /> 14 CCR§18459.1 (a)(b)(c)-Tire Program lD Number from CIWMB ` <br /> 0 0 _ <br /> 0 0 14 CCR§18459.2.1 -Submittal of Manifest Forms and Tire Trip Logs within 90 dayss,�tYy�1 <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 014 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> o o 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O <br /> 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> o O Other: § r y <br /> Comments jAr , <br /> Inspection Form Included: Q <br /> Comments Included: — – -- - - -- �' � <br /> Rusin 's n "pfi no Number Insp ig Phone Number <br /> INSTRUCTIONS ON BACK , s2oa1 <br /> :.,,. ,:- <br /> l 'X A-M P <br /> L T 2 FgN3 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy:LEA <br />